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VoIP News
News on VoIP continually updated from thousands of sources around the net.
Infographic: Why Schools are Switching to Fax-over-IP
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Wine Fest: 'It's a great time to work for children's charities'
Just as caterpillars turn into butterflies and grapes become wine, Naples Winter Wine Festival trustees hope their financial support of Collier County's children's charities will transform underprivileged children's lives.
That's why they've chosen "Nature's Transformations" for the theme of this year's festival. A look across the county reveals the world-famous festival, coveted for its spectacular vintners, world-class chefs and record-breaking fundraising, already has changed thousands of children's lives.
Check out the list of buildings, funded programs, construction projects and children who have been helped by the money raised from the festival — and the list goes on and on.
For starters, thanks in part to a $650,000 festival donation last year, the Boys & Girls Club of Collier County was able to open a new 36,000-square-foot building off Davis Boulevard, where hundreds of children get after-school care and learning opportunities they otherwise would never get.
In December, a $4 million festival grant triggered a $4 million University of Florida matching grant to build a UF pediatric dental residency school at Edison College in East Naples, where underprivileged children will get free dental care. Another $1 million festival donation launched a separate dental clinic set to open this year in East Naples for needy children.
Meanwhile, a Ronald McDonald Care Mobile travels countywide on $200,000 in festival funds, treating thousands of poor children who had been going to school in debilitating pain from decaying teeth.
In Immokalee, the festival donated $3 million for a state-of-the-art child-care building at the Guadalupe Center. A second $3 million building is in the works — doubling the number of preschool children who can get an academic head start while their parents work.
And for the first time this summer, more than 90 horseback riders with various kinds of disabilities rode through therapeutic training at the Naples Equestrian Challenge protected from the sun and rain under a $350,000 festival-funded roof.
Those are just some of the 28 children's charities that have benefited from the $39 million the festival has donated since 2001. Last year, the festival shattered the world's wine-auction record, raising $12.2 million in a single day.
The festival goal this year is to hit a $50 million total for the seven years — meaning this year's generous guests need to pull $11.2 million out of their collective wallets.
As a result of the benevolence, the voices of those who work at Collier County children's charities are reaching a crescendo in praise of festival organizers.
Listen to their joy, their thanks, their singing spirits as they speak of the 18 trustee couples or individuals who started this event, 16 of whom are still trustees:
"We think they are absolutely fantastic. They are really enthusiastic about our mission and goals," said Carolina Martino, president of the Naples Equestrian Challenge.
Lesa Peterson, project manager for Collier Health Services, which runs the Ronald McDonald Care Mobile and dental clinics, puts it this way: "They are changing the trajectory of children's lives. They are getting children off to a start they otherwise would not have."
Also last summer, 350 children got to attend the Boys & Girls Club summer program on the festival's donations.
"That's 350 kids a day that would not have been reached," said Greg Kimbrough, senior director of resource development at the Boys & Girls Club, which so far has received $5 million in festival proceeds.
Children like Walkins Lallemand, 16, know firsthand the impact that organizations such as the Boys & Girls Club can have on a young life. Walkins could have gone either way before he arrived at the club five years ago.
"He had that natural ability, that leadership that made other kids follow him. But you can be a negative leader," Kimbrough said. "We focused on putting him in roles where he could be a positive leader. And he's done amazing."
The club zoomed in on Walkins' academic abilities and now he's a scholarship student attending The Community School of Naples. Walkins is featured in the festival's 45-minute video, "NCEF: Transforming Children's Lives — One Agency at a Time," which can be seen online at www.naplesnews.com.
At the Shelter for Abused Women and Children, children who have been sexually abused are getting one-on-one counseling from therapists who wouldn't have been hired.
"We have seven children's (counselors) and the wine festival pays for five of them," said Hallie Devlin, director of services at the shelter.
In 2006, the festival gave the shelter $200,000.
"Each year they have done more for us than the year before," Devlin said.
The festival isn't just transforming children's lives, it's turning discouragement into hope for those on the front lines.
"When you work in areas where there are a lot of needs and not a lot of resources to do what needs to be done, people become discouraged," said Peterson, of Collier Health Services.
Today, if a children's charity in Collier County has a solid strategic plan, it can approach the festival's grant-making arm, the Naples Children and Education Foundation, NCEF, and find a listening ear and a helping hand, Peterson said.
Choosing a charity
Not all Collier children's charities are eligible for festival money. NCEF dollars go to agencies that provide medical and dental care, out-of-school support, early learning opportunities, special-needs care or services that enhance social well-being.
Bruce Sherman, NCEF chairman of the grant committee and founder of the investment company Private Capital Management, emphasizes that the NCEF mission is even narrower than that.
"The funds are to benefit indigent children, migrant children, children whose primary language is not English ... children who don't have the opportunities that the average child has in our society," he said.
"A lot of charities that apply serve middle-class children," Sherman said. "We turn those charities down because our intention here is to make a difference in the lives of those who ordinarily wouldn't have a chance."
The charities that land the grants go through a rigorous application process, present proposals to the nine-member committee and later open their books to festival scrutiny.
Sherman said the committee members log lots of hours picking the charities.
"We met for 30 or 40 hours in the evening just reviewing grant requests," Sherman said of the past year.
Then most of the trustees visited many of the applying agencies.
"We don't fund the same charities each year. We like to see them become self-sustaining. And we don't fund startups," Sherman said.
Stanley Boynton, president of the Guadalupe Center of Immokalee, said NCEF is strategic in its approach to helping.
"What they really do is strengthen the capacity of the organization in the long run for better service to the community," he said.
A second tier of NCEF grant-giving goes toward long-term strategic initiatives such as the commitment that landed the $4 million in UF matching funds for the pediatric dental school.
"We've made a $5.5 million total commitment," Sherman said, adding that $1.5 million will go to begin operations.
And this year, for the first time, NCEF has hired someone full time to evaluate the charitable organizations.
"Todd (Foege) OKs the financial condition of the charities, evaluates what he sees with his own eyes, and comes back and makes recommendations," Sherman said.
Foege, who has a master's degree in business administration, is the NCEF grant administrator.
"I review the overall financial health and I am paying close attention to how the NCEF dollars are being spent," Foege said.
Sometimes agencies drop off the list because the spending doesn't stand up to scrutiny.
But most of the charities on the receiving end don't mind the financial checkup.
"They hold us accountable. These are clearly very bright people who want to help children and want to be sure the agencies are spending the money wisely. But they are easy to work with," said Devlin of the local abuse shelter.
And they are making the job of working with needy children in Collier County so much easier.
"NCEF is bringing the resources to solve the problems," said Peterson of Collier Health Services. "It's a great time to work for children's charities."
- - -
The original organizers of the Naples Winter Wine Festival are: Mary Susan and J.D. Clinton; Denise and Brian Cobb; Arlene and Michael D'Alessandro; Shirlene and Bob Elkins; Sandy and Jim Figge; Connie and Tom Galloway; Valerie Boyd and Jeff Gargiulo; Mary Pat and Frank Hussey; Carol and Tom Lund; Scott Lutgert; Linda and Jim Malone; Joyce and Bill O'Meara; Pat Aluisi and Ned Sachs; Retta and Elliott Singer; Elizabeth and Clarke Swanson; Patti and George Wagner; Theresa and Tom Wajnert; and Dottie and Bryant Yunker.
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11515Re: [snowkiteidaho] [BSA] New Weather station
Expand Messages
- May 4, 2013I like the way you're thinking… Lets explore all the options so we can see what will work best long term.On May 4, 2013, at 6:23 PM, Jason Watt <jwattboi@...> wrote:Might be cost prohibitive. 2-300 cracked screen, otherwise 400+ for non broken units.Not sure if the hotspot will stay activated when only used periodically. I can donate mine for a week or so to test.
On May 4, 2013, at 18:13, RUSTY HILL <rustyshill@...> wrote:
that could work… how much for an broken iPad?On May 4, 2013, at 6:12 PM, Jason Watt <jwattboi@...> wrote:What about maybe a cheap cracked screen iPad with Verizon off eBay? Non contract data $20/month for 1GB.
On May 4, 2013, at 17:37, RUSTY HILL <rustyshill@...> wrote:
As of right now, Verizion wouldn't be the best bet as they require a contract and are much more expensive. That would require us to pay for service on months we have no need for the weather station. That's why we're trying to find someone who has a Sprint smartphone so we could sign up for a month to month service through Virgin, who uses Sprint's network.On May 4, 2013, at 5:16 PM, jwattboi <jwattboi@...> wrote:
Count me in for a contribution in funds. I've got an iPad with the Verizon 4G chip in it, I can run Speedtest.net on Verizon up there if you want. Let me know and I'll bring it next time.
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Qaddafi, Terrorism, and the Origins of the U.S. Attack on Libya
By Brian L. Davis
Qaddafi, Terrorism, and the Origins of the U.S. Attack on Libya
By Brian L. Davis
Davis's detailed account demonstrates that Libya was not an arbitrarily selected target but rather a justified one. He examines the context in which the April 15, 1986, U.S. military attack against Libya occurred. The history of U.S.-Libyan relations from the Nixon to the Reagan administration is covered in detail including the Rome and Vienna massacres and Operation Prairie Fire. A description of the final days leading to the attack include the La Belle Discotheque bombing, the U.S. decision to attack, preparations, the military operation itself, and its aftermath.
Related books and articles
- Books
- Journals
- Magazines
- Newspapers
- Encyclopedia
Libya and the United States: Two Centuries of Strife By Ronald Bruce St John University of Pennsylvania Press, 2002
The Libyan Arena: The United States, Britain, and the Council of Foreign Ministers, 1945-1948 By Scott L. Bills Kent State University Press, 1995
Peace and War: United States Foreign Policy, 1931-1941 By United States Department of State U.S. Government Printing Office, 1943
Power and Force: Libya's Relations with the United States By Nmoma, Veronica Journal of Third World Studies, Vol. 26, No. 2, Fall 2009
Speech by Deputy Minister of International Relations and Cooperation, Mr Ebrahim I Ebrahim, on the Occasion of a Public Lecture on "Libya, the United Nations, the African Union and South Africa: Wrong Moves? Wrong Motives?", University of Pretoria, 15 September 2011 By Strategic Review for Southern Africa, Vol. 33, No. 2, November 2011
Peer-reviewed publications on Questia are publications containing articles which were subject to evaluation for accuracy and substance by professional peers of the article's author(s).
Libya Opens Up By Murphy, Edward Harvard International Review, Vol. 22, No. 3, Fall 2000
Mass Tourism or Mass Confusion? with Libya Keen to Establish Normal, Post-Sanctions Relations with the International Community, Why Do There Still Seem to Be So Many Obstacles Put in the Way of Non-Arab Citizens Wishing to Use the Country as a Tourist Destination? Eamonn Gearon Reports from Tripoli By Gearon, Eamonn The Middle East, No. 382, October 2007
Is State's Pro-Libya Shift A Payback to Gore Ally? By Kincaid, Cliff Insight on the News, Vol. 16, No. 17, May 8, 2000
Libya Vows to Dismantle WMD Program By Kerr, Paul Arms Control Today, Vol. 34, No. 1, January/February 2004
US-Libya Relations off to Good Start, Rice Says after Meeting Gadhafi By Manila Bulletin, September 7, 2008
A Cold-War Chill? US-Russia Relations Falter over Libya and Syria By LaFranchi, Howard The Christian Science Monitor, March 3, 2012
Obama on Libya: The Dawn of a Foreign Policy Doctrine? By LaFranchi, Howard The Christian Science Monitor, April 4, 2011


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Icon Pack GO Launcher EX
- May 13, 2011
( 33)
Huge icon pack for GO Launcher! Includes over 800 icons in different styles and colors! This has something for everyone! App2SD supported.
How to use:
You must have GO Launcher EX installed for this app to work.
How to use:
1. Long press icon on your home screen
2. Press replace
3. Press Theme's Icon
4. Select Icon Pack from the drop down menu
Check out our other themes for GO Launcher!
Keywords: GO Launcher EX icon pack go dev team icon packs
Missing Majority of icons... Yea... I like some of the icon styles but after only a little bit of ways down, no icons show up even though you can continue scrolling. Not worth the money.
This app is impossible to find @ Androids market. Finally managed. Wish there were more apps like this
Love it! Been waiting forever for packs like this. Thank you! If only I knew why long pressing icon won't give me option to change it...
I payed for this :-( Keeps closing when scrolling down. Now I payed for this. I think you could at least fix it so we can use it. Come on get with it
Not Working Anymore This used to work great. Great icons, but it is no longer working. Anytime I try to use it, it freezes and crashes my whole phone.
A lot of icons, just not very many that stand out enough for me to wanna pay for them.


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Campbell, CAUSA
March 6, 2014
I actually researched the rules and learned to play on my own. I have played on the cell phone and computer numerous times - and got pretty good at it, but I have never played Euchre with physical cards. I am very interested in changing that. Card games on the computer are nice, but it's just not the same.
Canasta is one of my favorites along with its variations. Every now and then I enjoy cribbage and spades. I enjoy most rummy games. I don't know if this qualifies as a card game, but I have been interested in Mah Jong lately. It's like a rummy game played with Chinese tiles. I like the game itself, but unfortunately it's often played as a gambling game - and that isn't what I'm looking for at all.
I live in the South Bay, so I'm there more often. I do have business in the Peninsula and I get around, so it wouldn't be a big deal to have some fun in Menlo Park or San Mateo.
I am very interested in playing some classic card games. I belong to one other games group - it's a good group, but there's not much interest there in classics like Euchre.
The duration of the event was better than it was last time. Some of us had trouble finding each other in the crowd and confusion.
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A4C Coupon / All4Cellular Discount Code
Please use the banners above to start your shopping. We survive on commissions when you make a purchase.
Use discount code 'CIRCLEPHONE5′ when you buy 3 or more items. What you want to do is make your major purchase, then add some small things if you need them to qualify.
Cables, headphones, chargers, etc.
My last purchase for example was $125 for a tablet so that 5% discount was worth $6.25, which would get you enough to cover the 1 or 2 accessories you might add to make the 3 item purchase.


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Beebo is a cat with facial hair that smokes!
Ego City
A kid named Johnny has to stop the destruction of his city.
Foamy's Rant
Foamy likes to speak his mind about the things that piss him off!
I'm glad he's back!
Well, you sure made a great reappearance, salad fingers. No sleep for me tonight!
Wow, nice!
Really enjoy seeing this series continue onward! Such absurd and disturbing detritus you have here. I enjoy it's shambling and oozing presence greatly!
I'm honestly guessing he forgot that Yvonne was his "child" for a moment.
I have waited so long for this :)
Awesome flash, I have been waiting so long for this to come out. :) The episode was simply amazing!
Quite Lovely Auntie Breckenbridge
I love his vocabulary
also did anyone else notice the face in the furnace? kinda creeped me out


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HOME CBS Texas Longhorns Gear Texas Longhorns Shorts & Pants $40 to $60 (28 items) Product ID: 1222591
Main Content
You're the type of guy who loves to wear shorts year-round. Give your legs some sun while showing how much you love your Longhorns when you wear the Brickyard cargo shorts. These team-spirited shorts feature an embroidered Texas logo on the left cargo pocket and plenty of pockets to store your stuff in. They're also lightweight and comfortable so you can keep cool when the game heats up!
- 100% Cotton
- Imported
- Internal drawstring at waist
- Officially licensed collegiate product
- Quality embroidery
- Size 30 has a 9.5" inseam
- Two back pockets with button closure
- Two cargo pockets with dual-button closure
- Two front pockets
- Zipper fly with top button
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Special event items are produced by manufacturers only after the outcome of a game or event. These are advanced sale items and will ship immediately after they are received in our warehouse.
Manufacturer direct items are shipped directly from the manufacturer. These items are not available for international or expedited shipping.
Customized items can be personalized with options such as your name, your favorite number, and/or designs. Some options may be limited by league rules.


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A Reality Tour
by David Bowie
- Record Label: Sony Legacy
- Release Date: Jan 26, 2010
- Critic Score
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With 33 tracks stretching well over two hours, A Reality Tour isn't exactly suited to single-sitting listening. It's also far from a genuine greatest hits collection, though it certainly does feature a number of Bowie's most-loved songs. But it is a great document of one of the world's most inspirational recording artists.
Nobody really knows if Bowie is hanging up the spacesuit for good, since the man has been periodically announcing his retirement since 1973. But if so, this is one hell of an exit.
There are no user reviews yet.


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Watch: Cat Power Hilariously Skewers Her Reputation in Funny or Die Sketch
By Jenn Pelly on December 12, 2012 at 9:52 a.m. EST
Cat Power's reputation for on-stage meltdowns gets skewered in an incredible new Funny or Die skit, written and directed by Alex Fernie. In the video, she plays her artistically sensitive self, performing for a class of second-grade children.
Music Tapes' Julian Koster Sold His Banjo From In the Aeroplane Over the Sea to Fund Circus Tent Tour
By Jenn Pelly on August 21, 2012 at 3:51 p.m. EDT
What you see above is the banjo played by Julian Koster, of Elephant 6 band the Music Tapes, on Neutral Milk Hotel's In the Aeroplane Over the Sea. And it could be yours for $3,000, via a Kickstarter page launched by the Music Tapes to fund an ambitious and seemingly magical fall touring endeavor. (Thanks Scott Steinhardt for the tip.) UPDATE: The banjo has been sold.
Watch President Barack Obama Slow Jam the News With the Roots on "Late Night With Jimmy Fallon"
By Jenn Pelly on April 25, 2012 at 11:47 a.m. EDT
Here is one of the best things I have seen in my life:
Last night, President Barack Obama visited "Late Night With Jimmy Fallon" to discuss his plans to prevent Congress from raising the costs of federal student loans. But he didn't exactly just sit there and chat...
Video: LCD Soundsystem Become Legos
By Tom Breihan on July 27, 2011 at 1:10 p.m. EDT
The internet has done it again. A minor genius with too much time on his hands named Michael J. Green has done a shot-for-shot remake of LCD Soundsystem's classic video for "All My Friends", with animated legos standing in for James Murphy and friends.
It. Is. Amazing.
And even in a context as ridiculous as this, the song still raises goosebumps. Watch it below, via Vulture.
Listen: The Roots and "Weird Al" Cover Madvillain
By Tom Breihan on June 20, 2011 at 5:00 p.m. EDT
The Roots drummer and bandleader ?uestlove recently notched 1.6 million Twitter followers. To celebrate, the Roots recorded an instrumental cover of the Madvillain classic "Accordion". And since there aren't any accordion players in the Roots, they recruited arguably the most famous accordion player on the face of the earth: comedy-rock kingpin "Weird Al" Yankovic.
?uestlove posted the result on his Twitter, and you can listen to it here. The best part: The band members yelling all throughout that they can't believe this is happening. We can't either.
Yup, Washed Out's Album Cover Was in Cosmo
By Tom Breihan on May 3, 2011 at 2:25 p.m. EDT
Washed Out's debut album Within and Without, due July 12 from Sub Pop in the U.S. and Weird World/Domino internationally, has a pretty, um, eye-catching cover. As it turns out, that image also appeared in last month's issue of Cosmopolitan magazine, accompanying an article titled "Is This the Most Satisfying Sex Position?". See that photo in its other form here. (Thanks to Jenn Patchett for the tip.
More Flaming Lips Insanity: Stage Musical, Life-Size Gummi Wayne Coyne, Other Stuff
By Tom Breihan on April 4, 2011 at 12:40 p.m. EDT
Photo by Sanchez + Kitihara
If you're a Flaming Lips obsessive, the band is forcing you to work overtime in 2011. Thus far this year, they've already released a collaborative EP with Neon Indian that's only been made available at a few select record stores, as well as a piece that only plays when you've got a bunch of mobile phones ganged up together. They're also producing gummy skulls with USB drives embedded within. And now, frontman Wayne Coyne tells Billboard that the band has a bunch of other batshit projects in the works, including the long-in-the-works Yoshimi stage musical.
Video: Five-Year-Old Daniel Rossen of Grizzly Bear/Department of Eagles Impersonates Elvis
By Tom Breihan on February 14, 2011 at 2:50 p.m. EST
Well, this is awfully cute. Some kind soul has unearthed two ancient videos of Daniel Rossen, now a member of Grizzly Bear and Department of Eagles, doing Elvis impersonations when he was five. (Via Stereogum.) Video of any five-year-old doing Elvis impersonations is obviously cute, but somehow the knowledge that this guy is now an indie star puts it over the top.
Michael Cera Joins Mister Heavenly
By Tom Breihan on December 1, 2010 at 4:05 p.m. EST
Mister Heavenly photo by Johnny Le
Just yesterday, we reported that Mister Heavenly-- the supergroup featuring Man Man's Honus Honus, Islands' Nick Thorburn, and Modest Mouse's Joe Plummer-- had signed to Sub Pop and that they were gearing up for a tour with Passion Pit. Well, it turns out that the group may be even more super than we originally thought.
Last night, Mister Heavenly played their first show ever, at Seattle's Moore Theater. The Stranger reports that they had another member in their ranks: Honest-to-god movie star Michael Cera, playing bass.
Yo La Tengo Plan Insane Concept Tour
By Tom Breihan on November 3, 2010 at 3:50 p.m. EDT
Photo by Steve Gullick
When indie O.G.s Yo La Tengo hit the road early next year, they're not going to play any standard-issue greatest-hits-plus-new-shit sets. Instead, they're trying out an appealingly goofy show concept, one that'll probably lead them to stuff that they hardly ever play. Or show off their acting skills, if you're lucky.
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text:
|Número de publicación
|Tipo de publicación
|Número de solicitud
|Fecha de publicación
|1 May 2003
|Fecha de presentación
|26 Oct 2001
|Fecha de prioridad
|26 Oct 2001
|También publicado como
|Número de publicación
|Michael Hill
|Cesionario original
|Hill Michael R.S.
|Exportar cita
|BiBTeX, EndNote, RefMan
|Citas de patentes (5), Citada por (59), Clasificaciones (8), Eventos legales (4)
|Enlaces externos: USPTO, Cesión de USPTO, Espacenet
[0001] The present invention pertains to bi-ventricular cardiac pacing systems for improving cardiac function for heart failure patients that pace and sense in right and left ventricles of the heart and particularly pace in one of the right and left ventricles after an AV delay timed from a preceding atrial sense or atrial pace pulse characterized as an A-RVp delay and an A-LVp delay that are each determined from the intrinsic sensed A-RVs delay or the A-LVs delay to effect a fusion of delivered left ventricular pacing pulses with intrinsic depolarizations of the right ventricle.
[0002] Dual chamber pacing systems operating in the multi-programmable, VDD, DDD and DDDR pacing modes have been widely adopted in implantable dual chamber pacemakers and certain implantable cardioverter/defibrillators (ICDs) for providing atrial and ventricular synchronized pacing on demand. A DDD pacemaker implantable pulse generator (IPG) includes an atrial sense amplifier to detect atrial depolarizations or P-waves in the right atrium (RA) and generate an atrial sense event (A-EVENT) signal, a ventricular sense amplifier to detect ventricular depolarizations or R-waves in the right ventricle (RV) and generate a ventricular sense event (V-EVENT) signal, atrial and ventricular pacing pulse generators providing atrial and ventricular pacing (A-PACE and V-PACE) pulses, respectively, and an operating system governing pacing and sensing functions. If the atria fail to spontaneously beat within a pre-defined time interval (atrial escape interval), the pacemaker supplies an A-PACE pulse to the RA through an appropriate lead system. The IPG supplies a V-PACE pulse to the RV through an appropriate lead system at the time-out of an AV delay timed from a preceding A-EVENT or generation of an A-PACE pulse unless a non-refractory V-EVENT is generated in response to an R-wave during the AV delay. Such AV synchronous DDD pacemakers have the capability of tracking the patient's natural sinus rhythm and preserving the hemodynamic contribution of the atrial contraction over a wide range of heart rates.
[0003] A AV synchronous DDD pacemaker can operate in or be programmed to operate in the VDD mode when the atria function in a normal sinus rhythm between a programmed lower rate limit (LRL) and a programmmed upper rate limit (URL). Thus, the atria are not paced in the VDD pacing mode.
[0004] The rate-adaptive DDDR and VDDR pacing mode functions in the above-described manner but additionally provides rate modulation of a pacing escape interval between the programmable LRL and URL as a function of a physiologic signal or rate control parameter (RCP) developed by one or more physiologic sensors and related to the need for cardiac output. Reliance on the intrinsic atrial heart rate is preferred if it is appropriately between the URL and the programmed lower rate. At times when the intrinsic atrial rate is inappropriately high, a variety of "mode switching" schemes for effecting switching between tracking modes and non-tracking modes (and a variety of transitional modes) based on the relationship between the atrial rate and the sensor derived pacing rate have been proposed as exemplified by commonly assigned U. S. Pat. No. 5,144,949, incorporated herein by reference in its entirety.
[0005] The VDD, DDD and DDDR pacing modes were initially perceived to be of greatest benefit to cardiac patients whose hearts have an intact sinoatrial (SA) node that generates the atrial depolarizations detectable as P-waves, but also suffer defective A-V conduction, or AV block, wherein the ventricles fail to depolarize in synchrony with the atria. The RV is paced in the DDD pacing mode in synchrony with the atria after a timed out AV delay and is generally adequate to restore cardiac output for sedentary patients. Active patients with Sick Sinus Syndrome (SSS) have an intrinsic atrial rate that can be sometimes appropriate, sometimes too fast, and sometimes too slow. For SSS patients, the DDDR pacing mode provides some relief by pacing the atria and ventricles at a physiologic rate determined by an algorithm responsive to the RCP indicative of the patient's metabolic needs.
[0006] A loss of A-V electrical and mechanical synchrony can result in series of asynchronous atrial and ventricular depolarizations at independent rates that periodically result in an atrial depolarization that closely follows a ventricular depolarization. When this occurs, the left atrium (LA) contracts against a closed mitral valve, resulting in impeded venous return from the pulmonary vasculature due to increased atrial pressure and possibly even retrograde blood flow into the pulmonary venous circulation. As a result, the volume and pressure in the pulmonary venous circulation rise. Increased pulmonary pressures may lead to pulmonary congestion and dyspnea. Distension of the pulmonary vasculature may be associated with peripheral vasodilation and hypotension. In addition, the concomitant atrial distension is associated with increased production of atrial natriuretic factor and increases the susceptibility to atrial arrhythmias and possibly rupture of the atrial wall. Finally, turbulence and stagnation of blood within the atrium increase the risk of thrombus formation and subsequent arterial embolization. Maintenance of AV mechanical synchrony is therefore of great importance as set forth in greater detail in commonly assigned U. S. Pat. No. 5,626,623, incorporated herein by reference in its entirety.
[0007] Although DDD and DDDR pacing systems were initially offered to treat patients hearts exhibiting A-V conduction defects as described above, the value of dual chamber DDD or DDDR cardiac pacing treatment of patients suffering from HOCM (Hypertrophic Obstructive Cardiomyopathy) has been recognized in the literature. See, for example, "Permanent Pacing As Treatment For Hypertrophic Cardiomyopathy," by Kenneth M. McDonald et al., American Journal of Cardiology, Vol. 68, pp. 108-110, Jul. 1991. HOCM is characterized by a narrowed left ventricular outflow tract (LVOT), which causes a significant increase in the left ventricular end systolic pressure. The narrowed LVOT is caused by an increased thickness of the interventricular septum that obstructs blood flow out of the LV during systole, the time of cardiac ejection. Studies have indicated that patients suffering from HOCM may benefit from a specific mode of DDD pacing, wherein a V-PACE is delivered to the RV apex or septal wall in carefully timed AV synchrony with the preceding A-EVENT sensed in the RA or the preceding A-PACE delivered in the RA. Pacing the RV apex before spontaneous atrio-ventricular conduction activates the ventricles is understood to alter the ventricular septal activation pattern. Since the RV is caused to contract first, it pulls the septum toward the RV thereby reducing the LVOT obstruction.
[0008] The prior art techniques for AV synchronous pacing of HOCM patients, e.g., those disclosed in U.S. Pat. No. 5,340,361, recognize the necessity to periodically evaluate the pacing AV delay. The patient's intrinsic AV delay generally will change with heart rate, i.e., from rest to exercise. Moreover, simultaneous drug treatment such as beta blockers may also modify the intrinsic AV delay and require renewed evaluation of the AV delay. The importance of periodically making an accurate determination of the optimized pacing AV delay thus takes on significance. If the pacing AV delay is adjusted to a value that is too short, in order to ensure complete ventricular capture, the atrial contribution to ventricular filling may be compromised. However, if the pacing AV delay is adjusted to too great a value, ventricular capture is compromised, and there may be episodes of no ventricular pacing or the ventricular pace may not contribute the best possible reduction of the LVOT obstruction. Accordingly, it is important in this therapy to be able to continuously or periodically adjust the pacing AV delay to optimize it for HOCM therapy. Commonly assigned U.S. Pat. Nos. 5,534,506, 5,626,620, 5,626,623, 5,716,383, and 5,749,906 disclose ways of optimizing the pacing AV delay for pacing hearts exhibiting HOCM.
[0009] It has also been proposed that various conduction disturbances involving both bradycardia and tachycardia of a heart chamber could benefit from pacing pulses applied at multiple pace/sense electrode sites positioned in or about a single heart chamber or in the right and left heart chambers in synchrony with a depolarization which has been sensed at least one of the pace/sense electrode sites. It is believed that atrial and left ventricular cardiac output can be significantly improved when left and right chamber synchrony is restored, particularly in patients suffering from dilated cardiomyopathy (DCM) and congestive heart failure (CHF).
[0010] CHF is defined generally as the inability of the heart to deliver enough blood, i.e., to supply sufficient cardiac output, to the peripheral tissues to meet metabolic demands. Frequently CHF is manifested by left ventricular dysfunction (LVD), but it can have a variety of sources including HOCM, different conduction defects, cardiomyopathies, etc. 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 as shown in FIG. 1.
[0011]FIG. 1 is an illustration of transmission of the cardiac depolarization waves through the RA, LA, RV and LV of heart 10 in a normal electrical activation sequence at a normal heart rate with the conduction times exhibited thereon in seconds. The cardiac cycle commences normally with the generation of the depolarization impulse at the SA Node in the right atrial wall and its transmission through the atrial conduction pathways of Bachmann's Bundle and the Internodal Tracts at the atrial level into the left atrial septum. The RA depolarization wave reaches the AV node and the atrial septum within about 40 msec and reaches the furthest walls of the RA and LA within about 70 msec, and the atria complete their contraction as a result of the electrical activation. The aggregate RA and LA depolarization wave appears as the P-wave of the PQRST complex when sensed across external ECG electrodes and displayed. The component of the atrial depolarization wave passing between a pair of unipolar or bipolar pace/sense electrodes, respectively, located on or adjacent the RA or LA is also referred to as a sensed P-wave. Although the location and spacing of the external ECG electrodes or implanted atrial pace/sense electrodes has some influence, the normal P-wave width does not exceed 80 msec in width as measured by a high impedance sense amplifier coupled with such electrodes. A normal near field P-wave sensed between closely spaced bipolar pace/sense electrodes and located in or adjacent the RA or the LA has a width of no more than 60 msec as measured by a high impedance sense amplifier.
[0012] The depolarization impulse that reaches the AV Node is distributed inferiorly down the bundle of His in the intraventricular septum after a delay of about 120 msec. The depolarization wave reaches the apical region of the heart about 20 msec later and is then travels superiorly though the Purkinje Fiber network over the remaining 40 msec. The aggregate RV and LV depolarization wave and the subsequent T-wave accompanying re-polarization of the depolarized myocardium are referred to as the QRST portion of the PQRST cardiac cycle complex when sensed across external ECG electrodes and displayed. When the amplitude of the QRS ventricular depolarization wave passing between a bipolar or unipolar pace/sense electrode pair located on or adjacent the RV or LV exceeds a threshold amplitude, it is detected as a sensed R-wave. Although the location and spacing of the external ECG electrodes or implanted ventricular pace/sense electrodes has some influence, the normal R-wave width does not exceed 80 msec in width as measured by a high impedance sense amplifier. A normal near field R-wave sensed between closely spaced bipolar pace/sense electrodes and located in or adjacent the RV or the LV has a width of no more than 60 msec as measured by a high impedance sense amplifier. The typical normal conduction ranges of sequential activation are also described in the article by Durrer et al., entitled "Total Excitation of the Isolated Human Heart", in CIRCULATION (Vol. XLI, pp. 899-912, June 1970).
[0013] This normal electrical activation sequence becomes highly disrupted in patients suffering from advanced CHF and exhibiting an intra-atrial conduction defect (IACD) and/or an interventricular conduction defect (IVCD). A common type of intra-atrial conduction defect is known as or intra-atrial block (IAB), a condition where the atrial activation is delayed in getting from the RA to the LA. 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 RV and the LV is slowed, and the QRS is seen to widen due to the increased time for the activation to traverse the conduction path. These conduction defects exhibit great asynchrony between the RV and the LV due to conduction disorders along the Bundle of His, the Right and Left Bundle Branches or at the more distal Purkinje Terminals. Typical intra-ventricular peak—peak asynchrony can range from 80 to 200 msec or longer. In RBBB and LBBB patients, the QRS complex is widened far beyond the normal range to from >120 msec to 250 msec as measured on surface ECG. This increased QRS width demonstrates the lack of synchrony of the right and left ventricular depolarizations and contractions.
[0014] AV synchronized pacing of CHF hearts exhibiting DCM (CHF/DCM hearts) and lack of ventricular synchrony due to an IVCD of BBB condition do not necessarily benefit from the typically long AV delay that is determined to be optimal for HOCM patients. Frequently, CHF/DCM hearts exhibit intrinsic A-V (alternatively referred to as P-Q) conduction intervals or delays between 180 ms-260 ms with LBBB patterns or IVCD, and widened QRS complexes >120 ms, and also exhibit A-V conduction defects, including 1° AV Block (AVB). In time, the 1° AV Block can degenerate to 2° AV Block or 3° AV Block. Widened QRS Complexes (>120 ms), caused either by LBBB, IVCD, or RV paced evoked response, represent a significant delay in LV electrical activation and thus a significant delay in LV mechanical activation.
[0015] Optimal AV delay timing is obtained when the onset of LV contraction occurs_immediately upon completion of the LA contribution (Left Atrial Kick) in late diastole. At this moment, the LV filling (preload) is maximum, and the Frank-Starling Relationship between LV stretch and LV contraction is the greatest. This will result in maximum LV stroke volume ejection, and thus maximum Cardiac Index/Cardiac Output to be realized. To realize this exact A-V Sequential timing, the AV delay must be fully optimized.
[0016] Any delay between the completion of atrial contribution and the start of LV contraction can lead to "Pre-Systolic" mitral regurgitation, resulting in loss of effective LV filling and thus loss of LV stroke volume and reduced cardiac output. In addition, a too long AV delay reduces the diastolic time available for proper LVFT as observed on the diastolic Transmitral Inflow Pattern, resulting in a fusion of the transmitral inflow rapid filling phase (E wave) and active filling phase (A wave) of the Mitral Flow Relationship. A short, optimized AV delay, however, will allow maximum de-fusion of E and A waves, and a maximum LVFT to be realized at any given heart rate, contributing to increased cardiac output.
[0017] Thus, cardiac depolarizations that naturally occur in one upper or lower heart chamber are not conducted in a timely fashion either within the heart chamber or to the other upper or lower heart chamber diseased hearts exhibiting LVD and CHF. In such cases, the right and left heart chambers do not contract in optimum synchrony with each other, and cardiac output suffers due to the conduction defects. In addition, spontaneous depolarizations of the LA or LV occur at ectopic foci in these left heart chambers, and the natural activation sequence is grossly disturbed. In such cases, cardiac output deteriorates because the contractions of the right and left heart chambers are not synchronized sufficiently to eject blood therefrom. Hearts evidencing CHF with and without LVD have reduced ejection fraction from the LV thereby reducing stroke volume and promoting pulmonary edema limiting the patient's ability to exercise as described in commonly assigned U.S. Pat. No. 6,129,744. Furthermore, significant conduction disturbances between the RA and LA can result in left atrial flutter or fibrillation.
[0018] A number of proposals have been advanced for providing pacing therapies to alleviate heart failure conditions and restore synchronous depolarization and contraction of a single heart chamber or right and left, upper and lower, heart chambers as described in detail in the above referenced '744 patent and in commonly assigned U.S. Pat. Nos. 5,403,356, 5,797,970 and 5,902,324 and in U.S. Pat. Nos. 5,720,768 and 5,792,203. The proposals appearing in U.S. Pat. Nos. 3,937,226, 4,088,140, 4,548,203, 4,458,677, 4,332,259 are summarized in U.S. Pat. Nos. 4,928,688 and 5,674,259. The advantages of providing sensing at pace/sense electrodes located in both the right and left heart chambers is addressed in the '688 and '259 patents, as well as in U.S. Pat. Nos. 4,354,497, 5,174,289, 5,267,560, 5,514,161, and 5,584,867.
[0019] The medical literature also discloses a number of approaches of providing bi-atrial and/or bi-ventricular pacing as set forth in: Daubert et al., "Permanent Dual Atrium Pacing in Major Intra-atrial Conduction Blocks: A Four Years Experience", PACE (Vol. 16, Part II, NASPE Abstract 141, p.885, April 1993); Daubert et al., "Permanent Left Ventricular Pacing With Transvenous Leads Inserted Into The Coronary Veins", PACE (Vol. 21, Part II, pp. 239-245, January 1998); Cazeau et al., "Four Chamber Pacing in Dilated Cardiomyopathy", PACE (Vol. 17, Part II, pp. 1974-1979, November 1994); and Daubert et al., "Renewal of Permanent Left Atrial Pacing via the Coronary Sinus", PACE (Vol. 15, Part II, NASPE Abstract 255, p. 572, April 1992).
[0020] Typically, the bi-ventricular pacing systems described in the literature and in patents pace the RV and the LV simultaneously or separated by a programmable V-V pace delay, which is either an RV-LV pace delay or an LV-RV pace delay. Typically, in the prior art, the AV delay is timed out, the first V-PACE is delivered to one of the RV and LV, the V-V pace delay is timed out, and the second V-PACE is delivered to the other of the RV and LV. Or, an A-RV delay and an A-LV delay are started on the atrial pace or atrial sense event, and the RV-PACE and LV-PACE pulses are delivered to the RV and LV, in the predetermined sequence, when they time out. All of these delays are typically made programmable.
[0021] In the above-referenced '324 patent, an AV synchronous pacing system is disclosed providing three or four heart chamber pacing through pace/sense electrodes located in or adjacent one or both of the RA and LA and in or adjacent to both the RV and LV. One or two paced AV (PAV) delays defined to follow a selected one or both of the RA-PACE or LA-PACE and sensed AV (SAV) delays are timed from one of the RA-EVENT or the LA-EVENT. A non-refractory RV-EVENT or LV-EVENT detected at the respective RV or LV pace/sense electrodes during the time-out of the prevailing AV delay or V-A escape interval starts a conduction time window (CDW) timer. A LV-PACE or RV-PACE is delivered to the other of the LV or RV pace/sense electrodes at the time-out of the CDW if an LV-EVENT or RV-EVENT is not detected at that site while the CDW times out. The CDW can be set to zero, whereby RV-PACE and LV-PACE pulses are delivered simultaneously to the RV and LV upon time-out of the prevailing AV delay.
[0022] Recent findings of studies of such hearts has determined that each CHF/DCM heart has an optimal short AV delay that generates the highest cardiac output and provides the most physiologic hemodynamics as measured using echocardiography. See, "Effect of pacing chamber and atrioventricular delay on acute systolic function of paced patients with congestive heart failure" by Auricchio A, Stellbrink C, et al., CIRCULATION 1999, June 15;99 (23):2993-3001.
[0023] Short AV delays in the range of 60 ms-140 ms are typically recommended for bi-ventricular pacing to ensure ventricular capture and appropriate left ventricular filling. The relatively short AV delay is most optimally determined by testing the cardiac hemodynamic performance at differing AV delays.
[0024] The pacing regimens provided by these three and four chamber pacing systems are intended to achieve a shortening of the abnormally wide, intrinsically exhibited QRS complex, which is an attribute of most hearts exhibiting CHF with bundle branch block as described above. However, certain hearts exhibiting CHF do not exhibit abnormally wide QRS complexes, and cardiac output is not necessarily improved when bi-ventricular pacing is applied as described above. In fact, the bi-ventricular pacing can unduly widen the resulting evoked QRS complexes.
[0025] Moreover, the relatively short AV delays can cause an evoked contraction of the ventricles before the ventricles fill with blood from the atria.
[0026] The inventor has discovered that in certain hearts exhibiting CHF, cardiac output is enhanced by timing the delivery of an LV-PACE pulse such that evoked depolarization of the LV is effected in fusion with the intrinsic depolarization of the RV. The fusion depolarization enhances cardiac output in such hearts where the RV depolarizes first due to intact A-V conduction of a preceding intrinsic or evoked atrial depolarization wave front, but the A-V conducted depolarization of the LV is unduly delayed. The fusion depolarization of the LV is attained by timing the delivery of the LV-PACE pulse to follow, in time, the intrinsic depolarization of the RV but to precede, in time, the intrinsic depolarization of the LV. Advantageously, an RV-PACE pulse is not delivered due to the inhibition of the RV-PACE upon the RV-EVENT, allowing natural propagation of the wave front and depolarization of the septum, while an LV-PACE pulse is prematurely delivered in fusion with the RV depolarization.
[0027] The present invention is preferably implemented into a DDD/DDDR or VDD/VDDR pacing system that is capable of pacing and/or sensing in at least one atrial heart chamber and pacing and sensing in both the RV and LV. In a preferred operating mode, an A-RVP delay between an atrial pace (A-PACE) or sense event (A-EVENT), preferably an A-EVENT, and the delivery of an RV-PACE is established to ensure that it is longer than a measured intrinsic A-RVs conduction time. A non-refractory RV-EVENT then usually occurs and terminates the A-RVp before the RV-PACE can be delivered. An A-LVp delay between the A-PACE or A-EVENT and the delivery of an LV-PACE is established to ensure that it is shorter by a Δ value than a measured intrinsic A-LVs conduction time so that the LV-PACE pulse is delivered while the RV is spontaneously depolarizing. Preferably, the A-LVp delay is constrained to always be longer than the intrinsic A-RVs delay. This form of fusion pacing advantageously provides the longest filling time of blood from the left atrium into the left ventricle and then provides coordinated pumping of the blood from the right and left ventricles so that cardiac function is optimized.
[0028] The A-LVp delay is preferably periodically derived as a function of a measurement of the intrinsic A-LVs delay that is decremented by the Δ value. The intrinsic A-RVs delay is also measured and compared to the derived A-LVp delay. If the derived A-LVp delay becomes substantially equal to or shorter than the intrinsic A-RVs delay, then the A-RVp delay is decremented to be shorter than the A-LVp delay. Bi-ventricular pacing of the RV and LV is then established closely timed to the intrinsic RV and LV depolarizations. This back-up bi-ventricular pacing advantageously still maximizes the A-RVp and A-LVp delays and provides optimal cardiac function.
[0029] The above-described algorithm specifically applies to the case where the left ventricular activation follows the depolarization of the right ventricle after an inappropriate delay. It will be understood that the above-described algorithm can be employed in situations where this relation is reversed (e.g., RBBB).
[0030] This summary of the invention has been presented here simply to point out some of the ways that the invention overcomes difficulties presented in the prior art and to distinguish the invention from the prior art and is not intended to operate in any manner as a limitation on the interpretation of claims that are presented initially in the patent application and that are ultimately granted.
[0031] These and other advantages and features of the present invention will be more readily understood from the following detailed description of the preferred embodiments thereof, when considered in conjunction with the drawings, in which like reference numerals indicate identical structures throughout the several views, and wherein:
[0032]FIG. 1 is an illustration of transmission of the cardiac depolarization waves through the heart in a normal electrical activation sequence;
[0033]FIG. 2 is a schematic diagram depicting a three channel, atrial and bi-ventricular, pacing system in which the present invention is preferably implemented;
[0034]FIG. 3 is a simplified block diagram of one embodiment of IPG circuitry and associated leads employed in the system of FIG. 2 for providing three pacing channels that selectively functions in atrial synchronous, left ventricular or bi-ventricular pacing modes;
[0035]FIG. 4 is a comprehensive flow-chart illustrating a preferred VDD or DDD operating mode of the IPG circuitry of FIG. 3 providing bi-ventricular pacing in accordance with one embodiment of the invention;
[0036]FIG. 5 is a flow chart illustrating the steps in step S104 of FIG. 4 of delivering an RV-PACE pulse following time-out of an A-RVp delay unless an RV-EVENT terminates the A-RVp delay;
[0037]FIG. 6 is a flow chart illustrating the steps in step S106 of FIG. 4 of delivering an LV-PACE pulse following time-out of an A-LVp delay unless an LV-EVENT terminates the A-LVp delay; and
[0038]FIG. 7 is a flow chart illustrating the steps in step S100 of FIG. 4 of periodically deriving the A-RVp delay and the A-LVp delay as a function of the measured A-LVs delay.
[0039] In the following detailed description, references are made to illustrative embodiments for carrying out the invention. It is understood that other embodiments may be utilized without departing from the scope of the invention. For example, the invention is disclosed in detail in FIGS. 2 and 3 in the context of an AV sequential, bi-ventricular, pacing system operating in demand, atrial tracking, and triggered pacing modes in accordance with FIGS. 4 through 7 for restoring synchrony in depolarizations and contraction of the LV and RV in synchronization with atrial paced and/or atrial sensed events. This embodiment of the invention is programmable to operate as a three chamber pacing system having an AV synchronous operating mode for restoring upper and lower heart chamber synchronization and right and left atrial and/or ventricular chamber depolarization synchrony. The system can comprise the capabilities of one of the DDD/DDDR and VDD/DDR bi-ventricular pacing systems but preferably operates in the VDD operating mode wherein intrinsic atrial events govern the timing of the A-LVp and A-RVp delays. Of course, the present invention may also be practiced in a simpler, three-chamber VDD pacing system eliminating certain of the features of the preferred embodiment described herein.
[0040] It should be appreciated that the present invention may be utilized particularly to treat patients suffering various forms of heart failure, ventricular dysfunction or bradycardia. The pacing system of the present invention can also be incorporated into an anti-tachyarrhythmia system including specific high rate pacing and cardioversion shock therapies for providing staged therapies to treat a diagnosed tachyarrhythmia.
[0041] In accordance with an aspect of the present invention, a method and apparatus is provided to restore the depolarization sequence of FIG. 1 and the synchrony between the RV, septum, and LV that contributes to adequate cardiac output related to the optimal timed depolarizations of the RV and LV. This restoration is effected through providing optimally timed cardiac pace pulses to the LV and, as necessary, to the RV accounting for the particular implantation sites of the pace/sense electrodes in relation to each heart chambers.
[0042]FIG. 2 is a schematic representation of an implanted, three chamber cardiac pacemaker comprising a pacemaker IPG 14 and associated leads 16, 32 and 52 in which the present invention may be practiced. The pacemaker IPG 14 is implanted subcutaneously in a patient's body between the skin and the ribs. The three endocardial leads 16, 32 and 52 connect the IPG 14 with the RA, the RV and the LV, respectively. Each lead has at least one electrical conductor and pace/sense electrode, and a remote indifferent can electrode 20 is formed as part of the outer surface of the housing of the IPG 14. As described further below, the pace/sense electrodes and the remote indifferent can electrode 20 (IND_CAN electrode) can be selectively employed to provide a number of unipolar and bipolar pace/sense electrode combinations for pacing and sensing functions, particularly sensing far field signals, e.g. a far field R-wave (FFRS). The depicted positions in or about the right and left heart chambers are also merely exemplary. Moreover other leads and pace/sense electrodes may be used instead of the depicted leads and pace/sense electrodes that are adapted to be placed at electrode sites on or in or relative to the RA, LA, RV and LV.
[0043] The depicted bipolar endocardial RA lead 16 is passed through a vein into the RA chamber of the heart 10, and the distal end of the RA lead 16 is attached to the RA wall by an attachment mechanism 17. The bipolar endocardial RA lead 16 is formed with an in-line connector 13 fitting into a bipolar bore of IPG connector block 12 that is coupled to a pair of electrically insulated conductors within lead body 15 and connected with distal tip RA pace/sense electrode 19 and proximal ring RA pace/sense electrode 21. Delivery of atrial pace pulses and sensing of atrial sense events is effected between the distal tip RA pace/sense electrode 19 and proximal ring RA pace/sense electrode 21, wherein the proximal ring RA pace/sense electrode 21 functions as an indifferent electrode (IND_RA). Alternatively, a unipolar endocardial RA lead could be substituted for the depicted bipolar endocardial RA lead 16 and be employed with the IND_CAN electrode 20. Or, one of the distal tip RA pace/sense electrode 19 and proximal ring RA pace/sense electrode 21 can be employed with the IND_CAN electrode 20 for unipolar pacing and/or sensing.
[0044] Bipolar, endocardial RV lead 32 is passed through the vein and the RA chamber of the heart 10 and into the RV where its distal ring and tip RV pace/sense electrodes 38 and 40 are fixed in place in the apex by a conventional distal attachment mechanism 41. The RV lead 32 is formed with an in-line connector 34 fitting into a bipolar bore of IPG connector block 12 that is coupled to a pair of electrically insulated conductors within lead body 36 and connected with distal tip RV pace/sense electrode 40 and proximal ring RV pace/sense electrode 38, wherein the proximal ring RV pace/sense electrode 38 functions as an indifferent electrode (IND_RV). Alternatively, a unipolar endocardial RV lead could be substituted for the depicted bipolar endocardial RV lead 32 and be employed with the IND_CAN electrode 20. Or, one of the distal tip RV pace/sense electrode 40 and proximal ring RV pace/sense electrode 38 can be employed with the IND_CAN electrode 20 for unipolar pacing and/or sensing.
[0045] In this illustrated embodiment, a bipolar, endocardial coronary sinus (CS) lead 52 is passed through a vein and the RA chamber of the heart 10, into the coronary sinus and then inferiorly in a branching vessel to extend the proximal and distal LV CS pace/sense electrodes 48 and 50 alongside the LV chamber. The distal end of such a CS lead is advanced through the superior vena cava, the right atrium, the ostium of the coronary sinus, the coronary sinus, and into a coronary vein descending from the coronary sinus, such as the lateral or posteriolateral vein.
[0046] In a four chamber or channel embodiment, LV CS lead 52 could bear proximal LA CS pace/sense electrodes 28 and 30 positioned along the CS lead body to lie in the larger diameter CS adjacent the LA. Typically, LV CS leads and LA CS leads do not employ any fixation mechanism and instead rely on the close confinement within these vessels to maintain the pace/sense electrode or electrodes at a desired site. The LV CS lead 52 is formed with a multiple conductor lead body 56 coupled at the proximal end connector 54 fitting into a bore of IPG connector block 12. A small diameter lead body 56 is selected in order to lodge the distal LV CS pace/sense electrode 50 deeply in a vein branching inferiorly from the great vein GV.
[0047] In this case, the CS lead body 56 would encase four electrically insulated lead conductors extending proximally from the more proximal LA CS pace/sense electrode(s) and terminating in a dual bipolar connector 54. The LV CS lead body would be smaller between the LA CS pace/sense electrodes 28 and 30 and the LV CS pace/sense electrodes 48 and 50. It will be understood that LV CS lead 52 could bear a single LA CS pace/sense electrode 28 and/or a single LV CS pace/sense electrode 50 that are paired with the IND_CAN electrode 20 or the ring electrodes 21 and 38, respectively for pacing and sensing in the LA and LV, respectively.
[0048] In this regard, FIG. 3 depicts bipolar RA lead 16, bipolar RV lead 32, and bipolar LV CS lead 52 without the LA CS pace/sense electrodes 28 and 30 coupled with an IPG circuit 300 having programmable modes and parameters of a bi-ventricular DDDR type known in the pacing art. The IPG circuit 300 is illustrated in a functional block diagram divided generally into a microcomputer circuit 302 and a pacing circuit 320. The pacing circuit 320 includes the digital controller/timer circuit 330, the output amplifiers circuit 340, the sense amplifiers circuit 360, the RF telemetry transceiver 322, the activity sensor circuit 322 as well as a number of other circuits and components described below.
[0049] Crystal oscillator circuit 338 provides the basic timing clock for the pacing circuit 320, while battery 318 provides power. Power-on-reset circuit 336 responds to initial connection of the circuit to the battery for defining an initial operating condition and similarly, resets the operative state of the device in response to detection of a low battery condition. Reference mode circuit 326 generates stable voltage reference and currents for the analog circuits within the pacing circuit 320, while analog to digital converter ADC and multiplexer circuit 328 digitizes analog signals and voltage to provide real time telemetry if a cardiac signals from sense amplifiers 360, for uplink transmission via RF transmitter and receiver circuit 332. Voltage reference and bias circuit 326, ADC and multiplexer 328, power-on-reset circuit 336 and crystal oscillator circuit 338 may correspond to any of those presently used in current marketed implantable cardiac pacemakers.
[0050] If the IPG is programmed to a rate responsive mode, the signals output by one or more physiologic sensor are employed as a rate control parameter (RCP) to derive a physiologic escape interval. For example, the escape interval is adjusted proportionally the patient's activity level developed in the patient activity sensor (PAS) circuit 322 in the depicted, exemplary IPG circuit 300. The patient activity sensor 316 is coupled to the IPG housing and may take the form of a piezoelectric crystal transducer as is well known in the art and its output signal is processed and used as the RCP. Sensor 316 generates electrical signals in response to sensed physical activity that are processed by activity circuit 322 and provided to digital controller/timer circuit 330. Activity circuit 332 and associated sensor 316 may correspond to the circuitry disclosed in U.S. Pat. Nos. 5,052,388 and 4,428,378. Similarly, the present invention may be practiced in conjunction with alternate types of sensors such as oxygenation sensors, pressure sensors, pH sensors and respiration sensors, all well known for use in providing rate responsive pacing capabilities. Alternately, QT time may be used as the rate indicating parameter, in which case no extra sensor is required. Similarly, the present invention may also be practiced in non-rate responsive pacemakers.
[0051] Data transmission to and from the external programmer is accomplished by means of the telemetry antenna 334 and an associated RF transmitter and receiver 332, which serves both to demodulate received downlink telemetry and to transmit uplink telemetry. Uplink telemetry capabilities will typically include the ability to transmit stored digital information, e.g. operating modes and parameters, EGM histograms, and other events, as well as real time EGMs of atrial and/or ventricular electrical activity and Marker Channel pulses indicating the occurrence of sensed and paced depolarizations in the atrium and ventricle, as are well known in the pacing art.
[0052] Microcomputer 302 contains a microprocessor 304 and associated system clock 308 and on-processor RAM and ROM chips 310 and 312, respectively. In addition, microcomputer circuit 302 includes a separate RAM/ROM chip 314 to provide additional memory capacity. Microprocessor 304 normally operates in a reduced power consumption mode and is interrupt driven. Microprocessor 304 is awakened in response to defined interrupt events, which may include A-TRIG, RV-TRIG, LV-TRIG signals generated by timers in digital timer/controller circuit 330 and A-EVENT, RV-EVENT, and LV-EVENT signals generated by sense amplifiers circuit 360, among others. The specific values of the intervals and delays timed out by digital controller/timer circuit 330 are controlled by the microcomputer circuit 302 by means of data and control bus 306 from programmed-in parameter values and operating modes. In addition, if programmed to operate as a rate responsive pacemaker, a timed interrupt, e.g., every cycle or every two seconds, may be provided in order to allow the microprocessor to analyze the activity sensor data and update the basic A-A. V-A or V-V escape interval. In addition, the microprocessor 304 may also serve to define variable AV delays and the bi-ventricular V-V pace delays from the activity sensor data.
[0053] In one embodiment of the invention, microprocessor 304 is a custom microprocessor adapted to fetch and execute instructions stored in RAM/ROM unit 314 in a conventional manner. It is contemplated, however, that other implementations may be suitable to practice the present invention. For example, an off-the-shelf, commercially available microprocessor or microcontroller, or custom application-specific, hardwired logic, or state-machine type circuit may perform the functions of microprocessor 304.
[0054] Digital controller/timer circuit 330 operates under the general control of the microcomputer 302 to control timing and other functions within the pacing circuit 320 and includes a set of timing and associated logic circuits of which certain ones pertinent to the present invention are depicted. The depicted timing circuits include URI/LRI timers 364, V-V delay timer 366, intrinsic interval timers 368 for timing elapsed V-EVENT to V-EVENT intervals or V-EVENT to A-EVENT intervals or the V-V conduction interval, escape interval timers 370 for timing A-A, V-A, and/or V-V pacing escape intervals, an AV delay interval timer 372 for timing the A-LVp delay and A-RVp delay from a preceding A-EVENT or A-TRIG, a post-ventricular timer 374 for timing post-ventricular time periods, and a date/time clock 376.
[0055] In the present invention, the AV delay interval timer 372 is loaded with an appropriate A-RVP delay and an A-LVp delay as determined in FIG. 7 to time-out starting from a preceding A-PACE or A-EVENT. It should be noted that the V-V delay timer 366 could be employed to time out an equivalent V-V delay that represents the difference between the A-RVp delay and the A-LVp delay as determined in FIG. 7. In that case, the difference between the A-RVp delay and the longer A-LVp delay would be determined following the completion of the steps of FIG. 7. The interval timer 372 would time out the A-RVP delay, but typically not generate the RV-TRIG because of an RV-EVENT interrupting the timing, and then the V-V delay timer 366 would time out the difference and generate the LV-TRIG signal.
[0056] The post-event timers 374 time out the post-ventricular time periods following an RV-EVENT or LV-EVENT or a RV-TRIG or LV-TRIG and post-atrial time periods following an A-EVENT or A-TRIG. The durations of the post-event time periods may also be selected as programmable parameters stored in the microcomputer 302. The post-ventricular time periods include the PVARP, a post-atrial ventricular blanking period (PAVBP), a ventricular blanking period (VBP), and a ventricular refractory period (VRP). The post-atrial time periods include an atrial refractory period (ARP) during which an A-EVENT is ignored for the purpose of resetting any AV delay, and an atrial blanking period (ABP) during which atrial sensing is disabled.
[0057] It should be noted that the starting of the post-atrial time periods and the AV delays can be commenced substantially simultaneously with the start or end of the A-EVENT or the A-TRIG or, in the latter case, upon the start of end of the A-PACE which may follow the A-TRIG. Similarly, the starting of the post-ventricular time periods and the V-A escape interval can be commenced substantially simultaneously with the start or end of the V-EVENT or V-TRIG or, in the latter case, upon the start of end of the V-PACE which may follow the V-TRIG.
[0058] The microprocessor 304 also optionally calculates AV delays, post-ventricular time periods, and post-atrial time periods that vary with the sensor based escape interval established in response to the RCP(s) and/or with the intrinsic atrial rate.
[0059] The output amplifiers circuit 340 contains a RA pace pulse generator (and a LA pace pulse generator if LA pacing is provided), a RV pace pulse generator, and a LV pace pulse generator or corresponding to any of those presently employed in commercially marketed cardiac pacemakers providing atrial and ventricular pacing. In order to trigger generation of an RV-PACE or LV-PACE pulse, digital controller/timer circuit 330 generates the RV-TRIG signal at the time-out of the A-RVp delay and the LV-TRIG at the time-out of the A-LVp delay provided by AV delay interval timer 372 (or the V-V delay timer 366). Similarly, digital controller/timer circuit 330 generates an RA-TRIG signal that triggers output of an RA-PACE pulse (or an LA-TRIG signal that triggers output of an LA-PACE pulse if provided) at the end of the V-A escape interval timed by escape interval timers 370.
[0060] The output amplifiers circuit 340 includes switching circuits for coupling selected pace electrode pairs from among the lead conductors and the IND_CAN electrode 20 to the RA pace pulse generator (and LA pace pulse generator if provided), RV pace pulse generator and LV pace pulse generator. Pace/sense electrode pair selection and control circuit 350 selects lead conductors and associated pace electrode pairs to be coupled with the atrial and ventricular output amplifiers within output amplifiers circuit 340 for accomplishing RA, LA, RV and LV pacing.
[0061] The sense amplifiers circuit 360 contains sense amplifiers corresponding to any of those presently employed in commercially marketed cardiac pacemakers for atrial and ventricular pacing and sensing. As noted in the above-referenced, commonly assigned, '324 patent, it has been common in the prior art to use very high impedance P-wave and R-wave sense amplifiers to amplify the voltage difference signal which is generated across the sense electrode pairs by the passage of a cardiac depolarization. The high impedance sense amplifiers use high gain to amplify the low amplitude signals and rely on pass band filters, time domain filtering and amplitude threshold comparison to discriminate a P-wave or R-wave from background electrical noise. Digital controller/timer circuit 330 controls sensitivity settings of the atrial and ventricular sense amplifiers 360.
[0062] The sense amplifiers are uncoupled from the sense electrodes during the blanking periods before, during, and after delivery of a pace pulse to any of the pace electrodes of the pacing system to avoid saturation of the sense amplifiers. The sense amplifiers circuit 360 includes blanking circuits for uncoupling the selected pairs of the lead conductors and the IND_CAN electrode 20 from the inputs of the RA sense amplifier (and LA sense amplifier if provided), RV sense amplifier and LV sense amplifier during the ABP, PVABP and VBP. The sense amplifiers circuit 360 also includes switching circuits for coupling selected sense electrode lead conductors and the IND_CAN electrode 20 to the RA sense amplifier (and LA sense amplifier if provided), RV sense amplifier and LV sense amplifier. Again, sense electrode selection and control circuit 350 selects conductors and associated sense electrode pairs to be coupled with the atrial and ventricular sense amplifiers within the output amplifiers circuit 340 and sense amplifiers circuit 360 for accomplishing RA, LA, RV and LV sensing along desired unipolar and bipolar sensing vectors.
[0063] Right atrial depolarizations or P-waves in the RA-SENSE signal that are sensed by the RA sense amplifier result in a RA-EVENT signal that is communicated to the digital controller/timer circuit 330. Similarly, left atrial depolarizations or P-waves in the LA-SENSE signal that are sensed by the LA sense amplifier, if provided, result in a LA-EVENT signal that is communicated to the digital controller/timer circuit 330. Ventricular depolarizations or R-waves in the RV-SENSE signal are sensed by a ventricular sense amplifier result in an RV-EVENT signal that is communicated to the digital controller/timer circuit 330. Similarly, ventricular depolarizations or R-waves in the LV-SENSE signal are sensed by a ventricular sense amplifier result in an LV-EVENT signal that is communicated to the digital controller/timer circuit 330. The RV-EVENT, LV-EVENT, and RA-EVENT, LA-SENSE signals may be refractory or non-refractory, and can inadvertently be triggered by electrical noise signals or aberrantly conducted depolarization waves rather than true R-waves or P-waves.
[0064] To simplify the description of FIGS. 4 through 7, it will be assumed that the following references to an "A-EVENT" and "A-PACE" will be the RA-EVENT and RA-PACE, respectively, if there is no LA pacing or sensing provided or programmed on, or will be a programmed one of the RA-EVENT or LA-EVENT and RA-PACE or LA-PACE, respectively.
[0065] The possible operating modes of IPG circuit 300 are depicted in the flow chart of FIGS. 4-7 and described as follows. The particular operating mode of the present invention is a programmed or hard-wired sub-set of the possible operating modes as also described below. FIG. 4 illustrates the overall operations of the IPG circuit 300 during each pacing cycle and includes a further step S100 that is periodically entered into to derive the A-RVp and A-LVp delays (illustrated in FIG. 7) that are timed out in steps S104 (illustrated in FIG. 5) and S106 (illustrated in FIG. 6).
[0066] For convenience, the algorithm of FIGS. 4-7 is described as follows in the context of determining the A-RVp and A-LVp delays to optimally pace the left ventricle in fusion with an earlier, in time, depolarization of the right ventricle, which preferably depolarizes spontaneously after an intrinsic A-RVs delay as one example of the operations of the algorithm. As noted below, the algorithm can be employed to determine the A-RVp and A-LVp delays to optimally pace the right ventricle in fusion with an earlier, in time, depolarization of the left ventricle, which preferably depolarizes spontaneously after an intrinsic A-LVs delay.
[0067] When steps S104 and S106 are concluded it is expected that at least the LV-PACE will have been delivered, and time-out of the escape interval, e.g., a V-A escape interval, and the post-ventricular blanking and refractory periods is started in step S108. The RV and LV sense amplifiers and the atrial sense amplifier are enabled after the blanking periods to detect R-WAVES and P-waves and declare an RV-EVENT and an LV-EVENT in step S110 and an A-EVENT in step S112 during the time-out of the escape interval. The time-out of the escape interval is terminated and restarted upon declaration of any of any non-refractory RV-EVENT and LV-EVENT in step S110. The time-out of the escape interval is terminated or upon declaration of an A-EVENT in step S112 causing the A-RVp delay to be restarted in step S104 and the A-LVp delay to be restarted in step S106, unless the step of determining the optimal A-RVp delay and the A-LVp delay to be determined in step S100 as described below in reference to FIG. 7. The escape interval can be fixed as a programmed value in the VDD and DDD pacing mode or vary between programmed LPL and URL as a function of the RCP algorithm in VDDR and DDDR pacing modes
[0068] An A-PACE, comprising one (or both) of the RA-PACE and LA-PACE pulses, is delivered in step S116 if the V-A escape interval does time out as determined in step S114. It would be expected in practice that the V-A escape interval would be programmed to be greater than the intrinsic heart rate in patients whose atrial function is intact and provides normal sinus rhythm. Or, the pacing system can be provided as a VDD/DDR pacing system, eliminating sensing of P-waves. So, steps S114 and S116 would not be followed in such cases.
[0069] The intrinsic A-EVENT, comprising one of the RA-EVENT and the LA-EVENT, would therefore be more likely declared in step S112. Step S118 is optionally bypassed or practiced to adjust one or both of the A-RVp delay and the A-LVp delay as a function of the RCP algorithm or the measured, current intrinsic A-A interval. Then, the post-atrial blanking and refractory time periods are timed out in step S120, and the A-RVp delay is restarted in step S104 (FIG. 5) and the A-LVp delay is restarted in step S106 (FIG. 6), unless step S100 determining the optimal A-RVp delay and the A-LVp delay is entered as described below in reference to FIG. 7. It would be expected that step S100 would be practiced periodically at a programmed time of day, e.g., at night when the patient would be expected to be resting and heart rate and activity criteria are met, when an LV-EVENT is declared during time-out of the A-LVp delay, or when the RCP suggests a patient activity level exceeding a certain threshold.
[0070] In FIG. 5, the A-RVp delay is started in step S202 and timed out in step S204. As noted above, the A-RVp delay would normally be set to exceed the intrinsic A-RVs conduction time of the depolarization wave front from the atrium to the location of the RV sense electrodes, and so the delivery of the RV-PACE in step S206 would ordinarily be inhibited. However, there are conditions described further below where the A-RVp delay is shortened in step S100 such that the RV-PACE would be more likely to be delivered. When a non-refractory RV-EVENT is declared in step S208, then the algorithm advances to step S108 unless an optional feature is programmed ON as determined in step S210 to decrement the A-RVp delay in step S212.
[0071] In FIG. 6, the A-LVp delay is started in step S302 and timed out in step S304. As noted above, the A-LVp delay would normally be set to be shorter than the intrinsic A-LVs conduction time of the depolarization wave front from the atrium to the location of the LV sense electrodes, and so the LV-PACE would typically be delivered in step S306. However, there are conditions described further below where the LV-EVENT might be declared and the A-LVp delay shortened in step S100 such that the LV-PACE would be more likely to be delivered. In this case, when a non-refractory LV-EVENT is declared in step S308, the algorithm advances to step S108 unless an optional feature is programmed ON as determined in step S310 to decrement the A-LVp delay in step S312.
[0072] The adjustments to the A-RVp delay in step S212 and the A-LVp delay in step S312 can be programmed ON if it is found that the adjustments maintain the maximal filling time and maintain the improved coordination of RV and LV contraction effected by the delivery of the RV-PACE and/or LV-PACE in accordance with the algorithm of FIGS. 4-7. It is envisaged that other events could trigger adjustment of the A-RVp delay and/or the A-LVp delay as a function of changes in the intrinsic escape interval evidenced by a measured A-A interval, changes in the patient's physiologic requirements as evidenced by the RCP, or blood pressure or other sensor signals that are suggestive of a conduction delay or activation adjustment.
[0073] The adjustment step S100, illustrated in greater detail in FIG. 7, is commenced when the start criteria are met in step S400. Steps S102 and S104 are suspended until the declaration of the next A-EVENT or a number of A-EVENTS are counted. An A-RVs timer and an A-LVs timer are started in step S404 to enable determination of the intrinsic A-RVs delay in steps S406 and S408 and the intrinsic A-LVs delay in steps S410 and S412. Then, the intrinsic A-RVs delay and the intrinsic A-LVs delay are compared in step S414 to ensure that the intrinsic A-RVs delay exceeds the intrinsic A-LVs delay in step S416. Step S416 would be expected to be satisfied when the left ventricular activation is delayed in comparison to the right ventricular activation (e.g., LBBB).
[0074] In step S418, the A-LVp delay is adjusted to reflect the current measured intrinsic A-LVs delay by the formula A-LVp=A-LVs−Δ ms, where Δ ms is a programmed value, e.g., 10 ms, or is a an adaptive value, e.g., a percentage, e.g., 10%, of the measured intrinsic A-LVs conduction delay or the A-LVs/measured intrinsic A-A cycle length.
[0075] The adjusted A-LVP delay is then compared to the A-RVs in step S420 to ensure that the adjusted A-LVp delay is greater than the intrinsic A-RVs delay. If that condition is satisfied, then the A-RVp delay can be set to be longer than the measured intrinsic A-RVs delay in step S422 by the formula A-RVp=A-RVs+Δ ms, where Δ ms is a programmed value, e.g., 10 ms, or is a an adaptive value, e.g., a percentage, e.g., 10%, of the measured intrinsic A-LVs conduction delay or the A-LVs/measured intrinsic A-A cycle length or is programmed to zero.
[0076] If step S422 is followed, then the RV will not be paced, and the LV will be paced in fusion with the intrinsic depolarization of the RV.
[0077] If the condition of step S420 is not satisfied, then it is necessary to revert to bi-ventricular pacing wherein an RV-PACE is first delivered and an LV-PACE is then delivered. In step S424, the A-RVp delay is adjusted to reflect the current measured intrinsic A-RVs delay by the formula A-RVp=A-RVs−Δ ms, where Δ ms is a programmed value, e.g., 10 ms, or is a an adaptive value, e.g., a percentage, e.g., 10%, of the measured intrinsic A-LVs conduction delay or the A-LVs/measured intrinsic A-A cycle length.
[0078] The updated determined A-RVp and A-LVp delays are then stored in RAM memory to be employed in the pacing operating mode of FIG. 4 until the start criteria of step S400 are again satisfied and the A-RVp and A-LVp delays are again determined.
[0079] The above-described algorithm specifically applies to the case where the left ventricular activation follows the depolarization of the right ventricle after an inappropriate delay, e.g. a heart exhibiting LBBB. It will be understood that the above-described algorithm could be employed in situations where this relation is reversed, e.g., a heart exhibiting RBBB. In that case, the steps of the above-described algorithm could be followed substituting the operations pertaining to the right ventricle for those pertaining to the left ventricle.
[0080] Therefore, it will be understood that the present invention comprises a cardiac pacing system for and method of delivering ventricular pacing pulses to at least one of the right and left ventricles of the heart (which can be designated V1) wherein the delivery of the ventricular pacing pulse follows a preceding atrial event and follows, in time, the depolarization of the other of the right and left ventricles (which can be designated V2). In the above-described example, V1 comprises the left ventricle LV, and V2 comprises the right ventricle RV. However, V1 can comprise the right ventricle V2, and V1 can comprise the left ventricle. Therefore, the steps of the algorithm of FIGS. 4-7 can also be expressed substituting V1 for LV and V2 for RV. A ventricular atrio-ventricular delay (A-V1 p) from an atrial event (A) to time the delivery of a ventricular pacing pulse (V1 p) to ventricle V1 is thus established by: (1) sensing ventricular depolarizations of ventricle V1 as a ventricular sense (V1 s) event; (2) measuring the intrinsic atrial-ventricular delay between an atrial event and the V1 s event as an intrinsic A-V1 s delay; (3) sensing ventricular depolarizations of the ventricle V2 as a ventricular sense (V2 s) event; (4) measuring the intrinsic atrial-ventricular delay between an atrial event and the V2 s event as an intrinsic A-V2 s delay; and (5) determining an atrio-ventricular A-V1 p delay that is shorter than the intrinsic A-V1 s delay and longer than the intrinsic A-V2 s delay. The A-V1 p delay is timed from each atrial event, and the ventricular pacing pulse V1 p is delivered to the ventricle V1 at the timeout of the A-V1 p delay to effect fusion pacing of the ventricle V1 with intrinsic depolarization of the ventricle V2.
[0081] All patents and publications referenced herein are hereby incorporated by reference in their entireties.
[0082] It will be understood that certain of the above-described structures, functions and operations of the pacing systems of the preferred embodiments are not necessary to practice the present invention and are included in the description simply for completeness of an exemplary embodiment or embodiments. It will also be understood that there may be other structures, functions and operations ancillary to the typical operation of an AV synchronous, three or four chamber pacemaker that are not disclosed and are not necessary to the practice of the present invention. In addition, it will be understood that specifically described structures, functions and operations set forth in the above-referenced patents can be practiced in conjunction with the present invention, but they are not essential to its practice. It is therefore to be understood, that within the scope of the appended claims, the invention may be practiced otherwise than as specifically described without actually departing from the spirit and scope of the present invention.
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|Fee payment
Year of fee payment: 4
|24 Sep 2012
|Fee payment
Year of fee payment: 8


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The hearing of a PIL seeking direction against clearance to release Sunny Deol starrer 'Mohalla Assi' has been deferred to July 13. The petition filed by 'Hindu Front For Justice', a group of 11 local lawyers through their counsel HS Jain came up for hearing at the Allahabad High Court today.
Naya Umar Naya Choli [Bhojpuri Song] ft Ravi Kissan
Bhojpuri movie Song: Naya Umer Naya Choli Album: Dharmatma Singer: Udit Narayan, Kalpana
Ravi Kishan
A Delhi court on Tuesday (June 30) issued a stay order the release of Sunny Deol starrer 'Mohalla Assi' throughout the country saying a prima facie case was made out that the movie contained "filthy language" and hurt rel
Punjabi actor-singer Gippy Grewal is seen teasing Tina Ahuja, daughter of actor Govinda as 'Bad baby' in the new song from 'Second Hand Husband', a comedy film about love, marriages and divorce. The film marks the Bollywood debut Narmmadaa aka Tina, the trailer of which is already out.