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|N�mero de publicaci�n
|Tipo de publicaci�n
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|Fecha de publicaci�n
|20 Mar 2007
|Fecha de presentaci�n
|19 Feb 2003
|Fecha de prioridad
|19 Feb 2002
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|Pierre-Antoine Chapelon, Dany Berube, Hiep Nguyen, Faouzi Kallel
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|Citas de patentes (107), Otras citas (20), Citada por (111), Clasificaciones (13), Eventos legales (7)
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The present application claims priority under 35 U.S.C. �119 to U.S. Provisional Application Ser. No. 60/358,215, naming Chapelon et al. inventors, and filed Feb. 19, 2002, and entitled TRANSMURALITY ASSESSMENT DEVICE, the entirety of which is incorporated herein by reference in its entirety for all purposes.
1. Field of Invention
The present invention relates, generally, to tissue ablation instruments and lesion formation thereof, and more particularly, relates to apparatus and methodology for assessing tissue ablation transmurality.
2. Description of the Prior Art
It is well documented that atrial fibrillation, either alone or as a consequence of other cardiac disease, continues to persist as the most common cardiac arrhythmia. According to recent estimates, more than two million people in the U.S. suffer from this common arrhythmia, roughly 0.15% to 1.0% of the population. Moreover, the prevalence of this cardiac disease increases with age, affecting nearly 8% to 17% of those over 60 years of age.
Atrial arrhythmia may be treated using several methods. Pharmacological treatment of atrial fibrillation, for example, is initially the preferred approach, first to maintain normal sinus rhythm, or secondly to decrease the ventricular response rate. Other forms of treatment include drug therapies, electrical cardioversion, and RF catheter ablation of selected areas determined by mapping. In the more recent past, other surgical procedures have been developed for atrial fibrillation, including left atrial isolation, transvenous catheter or cryosurgical ablation of His bundle, and the Corridor procedure, which have effectively eliminated irregular ventricular rhythm. However, these procedures have for the most part failed to restore normal cardiac hemodynamics, or alleviate the patient's vulnerability to thromboembolism because the atria are allowed to continue to fibrillate. Accordingly, a more effective surgical treatment was required to cure medically refractory atrial fibrillation of the Heart.
On the basis of electrophysiologic mapping of the atria and identification of macroreentrant circuits, a surgical approach was developed which effectively creates an electrical maze in the atrium (i.e., the MAZE procedure) and precludes the ability of the atria to fibrillate. Briefly, in the procedure commonly referred to as the MAZE III procedure, strategic atrial incisions are performed to prevent atrial reentry circuits and allow sinus impulses to activate the entire atrial myocardium, thereby preserving atrial transport function postoperatively. Since atrial fibrillation is characterized by the presence of multiple macroreentrant circuits that are fleeting in nature and can occur anywhere in the atria, it is prudent to interrupt all of the potential pathways for atrial macroreentrant circuits. These circuits, incidentally, have been identified by intraoperative mapping both experimentally and clinically in patients.
Generally, this procedure includes the excision of both atrial appendages, and the electrical isolation of the pulmonary veins. Further, strategically placed atrial incisions not only interrupt the conduction routes of the common reentrant circuits, but they also direct the sinus impulse from the sinoatrial node to the atrioventricular node along a specified route. In essence, the entire atrial myocardium, with the exception of the atrial appendages and the pulmonary veins, is electrically activated by providing for multiple blind alleys off the main conduction route between the sinoatrial node to the atrioventricular node. Atrial transport function is thus preserved postoperatively as generally set forth in the series of articles: Cox, Schuessler, Boineau, Canavan, Cain, Lindsay, Stone, Smith, Corr, Change, and D'Agostino, Jr., The Surgical Treatment Atrial Fibrillation (pts. 1–4), 101 T
While this MAZE III procedure has proven effective in treating medically refractory atrial fibrillation and associated detrimental sequelae, this operational procedure is traumatic to the patient since this is an open-heart procedure and substantial incisions are introduced into the interior chambers of the Heart. Consequently, other techniques have been developed to interrupt atrial fibrillation restore sinus rhythm. One such technique is strategic ablation of the atrial tissues and lesion formation through tissue ablation instruments.
Most approved tissue ablation systems now utilize radio frequency (RF) energy as the ablating energy source. Accordingly, a variety of RF based catheters, medical instrument and power supplies are currently available to electrophysiologists. However, radio frequency energy has several limitations including the rapid dissipation of energy in surface tissues resulting in shallow "burns" and failure to access deeper arrhythmic tissues. Another limitation of RF ablation catheters is the risk of clot formation on the energy emitting electrodes. Such clots have an associated danger of causing potentially lethal strokes in the event that a clot is dislodged from the catheter. It is also very difficult to create continuous long lesions with RF ablation instruments.
As such, instruments which utilize other energy sources as the ablation energy source, for example in the microwave frequency range, are currently being developed. Microwave frequency energy, for example, has long been recognized as an effective energy source for heating biological tissues and has seen use in such hyperthermia applications as cancer treatment and preheating of blood prior to infusions. Accordingly, in view of the drawbacks of the traditional catheter ablation techniques, there has recently been a great deal of interest in using microwave energy as an ablation energy source. The advantage of microwave energy is that it is much easier to control and safer than direct current applications and it is capable of generating substantially larger and longer lesions than RF catheters, which greatly simplifies the actual ablation procedures. Such microwave ablation systems are described in the U.S. Pat. No. 4,641,649 to Walinsky; U.S. Pat. No. 5,246,438 to Langberg; U.S. Pat. No. 5,405,346 to Grundy, et al.; and U.S. Pat. No. 5,314,466 to Stern, et al, each of which is incorporated herein by reference.
Regardless of the energy source applied to ablate the arrhythmic tissues, these strategically placed lesions must electrically sever the targeted conduction paths. Thus, not only must the lesion be properly placed and sufficiently long, it must also be sufficiently deep to prevent the electrical impulses from traversing the lesion. Ablation lesions of insufficient depth may enable currents to pass over or under the lesion, and thus be incapable of disrupting, or otherwise interrupting, the reentry circuits. In most cases, accordingly, it is desirable for the ablation lesion to be transmural.
To effectively disrupt electrical conduction through the cardiac tissue the tissue temperature must reach a threshold where irreversible cellular damage occurs. The temperature at the margin between viable and nonviable tissue has been demonstrated to be about 48� C. to about 50� C. Haines et al. Haines D E, Watson D D, Tissue heating during radiofrequency catheter ablation: a thermodynamic model and observations in isolated perfused and superfused canine right ventricular free wall, Pacint Clin Electrophysiol, June 1989, 12(6), pp. 962–76.)
Thus, to ensure ablation, the tissue temperature should exceed this margin. This, however, is often difficult to perform and/or assess since the cardiac tissue thickness varies with location and, further, varies from one individual to another.
Most tissue ablation instruments typically ablate tissue through the application of thermal energy directed toward a targeted biological tissue, in most cases the surface of the biological tissue. As the targeted surface of the biological tissue heats, for example, the ablation lesion propagates from the targeted surface toward an opposed second surface of the tissue. Excessive thermal energy at the interface between the tissue and the ablation head, on the other hand, is detrimental as well. For example, particularly with RF energy applications, temperatures above about 100� C. can cause coagulation at the RF tip. Moreover, the tissue may adhere to the tip, resulting in tearing at the ablation site upon removal of the ablation instrument, or immediate or subsequent perforation may occur. Thin walled tissues are particularly susceptible.
Generally, if the parameters of the ablation instrument and energy output are held constant, the lesion size and depth should be directly proportional to the interface temperature and the time of ablation. However, the lag in thermal conduction of the tissue is a function of the tissue composition, the tissue depth and the temperature differential. Since these variables may change constantly during the ablation procedure, and without overheating the tissues at the interface, it is often difficult to estimate the interface temperature and time of ablation to effect a proper transmural ablation, especially with deeper arrhythmic tissues.
Several attempts have been made to assess the completion or transmurality of an ablation lesion. The effective disruption of the electrical conduction of the tissue does of course affect the electrical characteristics of the biological tissue. Thus, some devices and techniques have been developed which attempt to measure at least one of the electrical properties, such as those based upon a function of impedance (e.g., its value, the change in value, or the rate of change in value) of the ablated tissue, to determine whether the ablation is transmural and complete. Typical of these devices include U.S. Pat. No. 6,322,558 to Taylor et al. and U.S. Pat. No. 5,403,312 to Yates et al.; U.S. patent application Ser. No. 09/747,609 to Hooven; and WIPO Pub. No. WO 01/58373 A1 to Foley et al., each of which is incorporated by reference in its entirety.
While these recent applications have been successful in part, they all tend to measure the electrical properties of the targeted ablation tissue directly from the surfaces of the tissue (i.e., the top surface or the underside surface of the tissue). This may be problematic since the measurement of such electrical properties can produce false indications with respect to transmurality of the ablation; a decrease in the change of impedance measured across the lesion indicative of transmurality, however, knowing there is insufficient energy applied to truly created a transmural lesion, as one example.
Accordingly, it would be advantageous to provide an apparatus and method to better assess the transmurality of an ablation lesion during an ablation procedure, for instance, by providing certain tissue characteristic measurements from one surface of a bodily organ or from two opposing surfaces or from one surface relative the blood pool. Furthermore, it would be advantageous to provide digital signal processing to the tissue measurement obtained in order to better assess the transmurality of a newly created ablation lesion.
The present invention provides a measurement accessory or instrument useful for facilitating tissue ablation procedures of sensitive biological tissue such as those of internal organs. In particular, the present invention is suitable for assessing the transmurality of an ablation lesion formed from a first surface of cardiac tissue of the heart to an opposed second surface thereof to electrically isolate conduction paths thereof during treatment of arrhythmia.
The measurement instrument may be part of an ablation system or an accessory thereto. The instrument or accessory includes at least a first sensor which is positioned proximate a first tissue surface, and at least a second sensor positioned proximate a second tissue surface. The first sensor is adapted to transmit a first signal. The second sensor is adapted to interpret a signal responsive to the first signal, the responsive signal being related to one or more tissue characteristics observed during the creation of an ablation lesion. These measurements can then be analyzed to determine the transmurality or effectiveness of the ablation procedure.
Accordingly, by collectively analyzing this measured data, a surgeon may gauge whether an ablation procedure has been properly performed. Unlike the current transmurality assessment procedures, the present invention is capable of conducting measurements through the means of very simple and straight forward purse string openings leading to the interior of the organ and placement of various sensors therein.
In one specific embodiment, the first and second sensors are electrodes to measure the electrical characteristics to measure at least one of conduction time, conduction velocity, phase angle, and impedance through at least a portion of the targeted tissue. Using this information, audio or visual feedback may be provided to determine the ablation transmurality, or other lesion characteristic. In other examples, the feedback information may be applied for automatic closed-loop control of the energy applied to the target tissue by a tissue ablation instrument.
In another embodiment, the second electrode is provided on the distal end of an elongated shaft placed within the interior of an organ, through a purse string opening for example. The second electrode, while perhaps not in direct contact with a tissue surface opposed to the first electrode, electrically communicates a signal responsive to the transmitted signal from the first electrode.
In another aspect of the present invention, a tissue ablation assembly is provided that is adapted to ablate a targeted biological tissue from a first surface thereof to an opposed second surface thereof to form an ablation lesion. The ablation assembly includes an elongated transmission line having a proximal portion suitable for connection to an energy source. An antenna assembly is coupled to the transmission line, and is adapted to transmit energy therefrom sufficiently strong to cause tissue ablation at the first surface. A manipulating device may be included which cooperates with the ablation assembly for manipulative movement thereof. A first sensor is further included and positioned within at least a portion of the ablative zone of the antenna assembly. The first sensor cooperates with a second sensor located proximate to a second tissue surface opposed to the first tissue surface. The second sensor is operatively attached to a needle member adapted to pierce the outer surface of the organ and advance to a point interior to the organ, proximate to the second tissue surface opposed to the first tissue surface.
In yet another aspect of the present invention, a method is provided for assessing the transmurality of an ablation lesion from a first surface of a targeted biological tissue to an opposed second surface thereof. The method includes placing a first sensor proximate a first surface of a target tissue and placing a second sensor proximate to a second opposing surface of the target tissue. Once the sensors are placed, a first signal is transmitted from the first sensor. The first signal propagates through at least a portion of the target tissue and a signal responsive to the first signal is received by the second sensor, the responsive signal being related to one or more of conduction time, conduction velocity, phase angle, and impedance through at least a portion of the targeted tissue, to determine the transmurality of the ablation lesion created or being created. The method further includes utilization of digital signal processing to better evaluate the measured responsive signal and, thus, better assess transmurality during or after the ablation lesion is being created.
Another method is included for forming a transmural lesion from a first surface of a targeted biological tissue to an opposed second surface thereof. The method includes manipulating an antenna assembly of an ablation instrument into engagement with or substantially adjacent to the tissue first surface, and generating an electromagnetic field from the antenna assembly sufficiently strong to cause tissue ablation to the tissue first surface. The antenna assembly includes at least a first electrode. The method further includes piercing a needle member, having an elongated shaft, into the targeted biological tissue from the tissue first surface. The needle member includes at least a second electrode, the second electrode being placed proximate a second tissue surface opposed to the antenna assembly placement. Transmitting and receiving electrical signals by and between the first and second electrodes is performed to measure at least one of conduction time, conduction velocity, phase angle, and impedance through a portion of the biological tissue.
In one specific configuration, the method includes engaging the second electrode with the tissue second surface. The piercing event includes driving the shaft into the organ, placing the second electrode in contact with the tissue second surface proximate to the ablation lesion during or after creation. In another specific configuration, the second electrode is placed with the bodily organ proximate to the tissue second surface. The piercing event includes driving the shaft into the organ, holding the second electrode suspended therein. Subsequently, the method includes measuring the at least one of conduction time, conduction velocity, phase angle, and impedance between the first and second electrodes.
In yet another aspect of the present, a method for treating medically refractory atrial fibrillation of the heart is provided. This method includes manipulating an antenna assembly of an ablation instrument into engagement with or substantially adjacent to a first surface of targeted cardiac tissue of the heart, and generating an electromagnetic field from the antenna assembly sufficiently strong to cause tissue ablation to the first surface to form an ablation lesion extending from the first surface toward an opposed second surface of the heart. The antenna assembly includes a first electrode attached thereto. In accordance with this aspect of the present invention, before, during or after generating, the method next includes piercing a needle member having an elongated shaft into cardiac tissue from the heart epicardial surface. The needle member includes at least a second electrode which is placed proximate to an endocardial surface of the heart. Next the method includes transmitting and receiving electrical signals to measure at least one of conduction time, conduction velocity, phase angle, and impedance through at least a portion of the targeted cardiac to determine the transmurality of the ablation lesion. The manipulating, generating, piercing and measuring events are repeated to form a plurality of strategically positioned ablation lesions and/or to divide the left and/or right atria to substantially prevent reentry circuits.
In one specific embodiment, the ablation lesions are strategically formed to create a predetermined conduction pathway between a sinoatrial node and an atrioventricular node of the heart. In another application, the manipulating, generating, piercing and measuring are repeated in a manner isolating the pulmonary veins from the epicardium of the heart.
The assembly of the present invention has other objects and features of advantage which will be more readily apparent from the following description of the best mode of carrying out the invention and the appended claims, when taken in conjunction with the accompanying drawing, in which:
While the present invention will be described with reference to a few specific embodiments, the description is illustrative of the invention and is not to be construed as limiting the invention. Various modifications to the present invention can be made to the preferred embodiments by those skilled in the art without departing from the true spirit and scope of the invention as defined by the appended claims. It will be noted here that for a better understanding, like components are designated by like reference numerals throughout the various Figures.
Turning now to the Figures, a measurement or assessment instrument or device, generally designated 20 in
The measurement or assessment instrument 20 includes at least a first sensor 31 a and at least a second sensor 31 b. Sensor 31 a is configured to engage the first surface 22 of the target tissue 23 and, while it can be place proximate or underneath a portion of the ablation instrument 26, sensor 31 a is preferably operably attached to the ablation instrument 26. Sensor 31 b is operably positioned proximate to the second surface 25 of tissue 23 and, more preferably, directly opposed to the ablation instrument 26. As will become more apparent with the discussion below, while the sensor 31 b may be placed anywhere within a hollow organ, if the sensor 31 b is placed in contact with the second tissue surface 25, placement opposing the instrument 26 is preferable as such placement improves measurement and analysis of the acquired tissue characteristic.
Sensor 31 b is mounted upon an elongated shaft 40 for placement. As stated above, the sensor 31 b can be placed anywhere within a hollow organ, the left ventricle of a heart for example. If it is desirable to place the sensor 31 b in contact with the second tissue surface 25, the elongated shaft may be made malleable to allow for actively forcing the sensor 31 b into contact with the tissue surface 25, or otherwise encouraging such placement. Additionally, the distal end of shaft 40 may be pointed to allow for piercing and advancing through the tissue 23. The shaft 40 is sized to allow the elastic and resilient epicardial surface to close the opening created when the shaft 40 is removed. Alternatively, the shaft may be placed into position through the use of a purse string opening, well known in the art.
As shown, sensor 31 b may be an elongated electrode surrounding a distal portion of shaft 40. However, sensor 31 b may alternatively comprise several sensors 31 b 1–bn along the distal portion of shaft 40 (not shown), each sensor 31 b 1–bn being selectively and operably attached to a data acquisition system, providing a more detailed analysis, as discussed in more detail below, of the propagation of the ablation lesion 21 through the tissue 23.
Placing the sensor 31 b in contact with the second tissue surface 25 is advantageous since such placement displaces fluids or other materials which would interfere with creation of the lesion, cooling the tissue for example. Thermal isolation of the second tissue surface 25 may be enhanced by adapting shaft 40 to cover more tissue surface 25 area, isolating the tissue surface 25 from fluids such as blood flow, as generally depicted by arrow B. For example, the cross-sectional geometry of the distal shaft 40 may be rectangular, engaging more tissue and, thus, thermally isolating more tissue from fluids, such as blood.
Briefly, the present invention is suitable for use in connection with tissue ablation instruments adapted to ablate the biological tissue walls of internal organs and the like. These tissue walls typically have wall thickness from one surface of the tissue to an opposite surface of the tissue in the range of about 2 mm to about 10 mm. Thus, through direct contact with or exposure of the one surface of the tissue to an ablation assembly 32 of the ablation instrument 26, the formation of the ablation lesion generally propagates from the one surface toward the opposed second surface of the tissue. It will be understood, however, and as set forth below, that any modality of ablative energy may be applied.
As generally shown in
Any source of ablative energy may be employed to achieve ablation. These include, but are not limited to, Radio Frequency (RF), laser, cryogenic, ultrasound, one or more resistive heating elements, microwave, or any other energy which can be controllably deployed to ablate tissue. The source of ablation can also be one or a family of chemical agents. For example, localized ethanol injection can be used to produce the ablation lines. RF probes that apply an RF conduction current in the range of about 450 kHz to about 550 kHz. Typical of these RF ablation instruments include ring electrodes, coiled electrodes or saline electrodes. Another source of ablative energy are laser based energy sources sufficient to ablate tissue. These include CO2 or Nd: YAG lasers which are transmitted to the ablation assembly 32 through fiber optic cable or the like. Yet another alternative energy source is cryogenic energy. These cryogenic probes typically apply a cryogenic fluid, such as a pressurized gas (e.g., Freon), through an inflow lumen to a decompression chamber in the ablation assembly. Upon decompression or expansion of the pressurized gas, the temperature of the ablation assembly is sufficiently reduced to cause tissue ablation upon contact therewith. The ablative energy may also be ultrasonically based. For example, one or a series of piezoelectric transducers may be provided as an ablative element which delivers acoustic waves sufficient to ablate tissue. Such transducers include piezoelectric materials such as quartz, barium oxides, etc. It should be noted that, in some cases, the sensors 31 may be an integral part of the ablating element itself, an RF electrode adapted to emit ablative energy there from for example.
One particularly effective source of ablative energy, however, is microwave energy which is emitted as an electromagnetic field by the ablation assembly. One advantage of microwave energy, as mentioned, is that the field is easier to control and safer than direct current applications. Typically, the microwave energy permeates the tissue to a depth proportional to the energy applied. The microwave probes, further, are capable of generating substantially larger and longer lesions than RF catheters, which greatly simplifies the actual ablation procedures. Moreover, recent advances in the antenna assembly designs enable even greater control of the field emission in predetermined directions for strategic lesion formation.
Briefly, referring back to
Preferably, sensor electrodes 31 are provided by ring electrodes of various dimensions, as described herein. Such electrodes may be composed of a conductive or metallic material, such as silver, platinum or other biocompatible metals suitable for the purposes described herein. Nonmetallic conductive electrodes like Ag—AgCl, or saline electrodes could also be used.
Each sensor 31 a is coupled to a respective transmission line 42 to electrically transmit from a signal source or generator. In a similar fashion, each sensor 31 b is coupled to a respective transmission line 42 to electrically transmit a signal from the second tissue surface 25 to a processing unit (not shown).
The outer surface of ablation instrument 26 may be grooved or defined with a plurality of annular slots 44 formed and dimensioned for receipt of the one or more sensors 31 a therein. Preferably, the width and depth of each slot 44 is substantially similar to that of the respective sensor 31 so that it may be seated generally flush with the exterior surface of the instrument 26, and substantially free of gaps or spaces. This would facilitate placement of the ablation instrument 26 upon the tissue first surface 22.
Briefly turning also to
The ablation instrument 26 includes a manipulating device 38 which cooperates with the ablation assembly 32 to orient the antenna and shield device in position to perform the desired ablation. This manipulating device 38, for example, may include a handle member or the like coupled to the ablation assembly, as shown in
Briefly, when microwave energy is applied, the power supply (not shown) will include a microwave generator which may take any conventional form. The optimal frequencies are generally in the neighborhood of the optimal frequency for heating water. By way of example, frequencies in the range of approximately 800 MHz to 6 GHz work well. Currently, the frequencies that are approved by the Federal Communication Commission (FCC) for Industrial, Scientific and Medical work includes 915 MHz and 2.45 GHz and 5.8 GHz (ISM band). Therefore, a power supply having the capacity to generate microwave energy at frequencies in the neighborhood of 2.45 GHz may be chosen. A conventional magnetron of the type commonly used in microwave ovens is utilized as the generator. A solid-state amplifier could also be used. It should be appreciated, however, that any other suitable microwave power source (like a Klystron or a traveling-wave tube (TWT)) could be substituted in its place, and that the explained concepts may be applied at other frequencies like about 434 MHz, 915 MHz or 5.8 GHz (ISM band).
Turning also to
It is important to note that the transmural assessment procedure of
Now turning specifically to
Generally, data is acquired over a period of time, thus, a number of data points will be collected and analyzed as part of the methods described herein. More specifically, a determination is made in a step 64 a as to whether this is the first evaluation performed for a given ablation process, referred to herein as a first run. If this is a first run, a normalization of the acquired data is performed in a step 64 b. Normalization is achieved through the initial acquisition of a plurality of data points over a period of time. In this way, future acquired data can be compared, or otherwise evaluated, with respect to this normalized value rather than an actual value. This is advantageous since it allows for evaluation of the tissue characteristic measurement as an overall trend, observing decreasing or increasing values for example. Data acquisition during normalization can involve conditioning and processing the data as described immediately below with respect to further steps as part of the evaluation procedure.
After normalization, the acquired data is conditioned in a filtering step 64 c. The filtering acts to remove undesirable signals induced by transmitted signals, as discussed herein, by inconsistent contact between a sensor 31 and a tissue surface or by movements of sensors 31 within a chamber of a hollow organ related to physiological events, a heart beat for example. While the filtered signal resulting from the filtering step 64 c may be utilized to provide a transmurality assessment determination, the value obtained may be processed further to enhance the assessment determination in a step 64 d. As described herein, one parameter to observe is decreasing impedance during creation of an ablation lesion. While the current value of measured impedance can be compared with previous values to assess transmurality, estimation of the of the line representative of the measured impedance, using the least mean square calculation, may be determined and compared to a predetermined value, close to zero for example, providing an indication of transmurality. It should be apparent that certain analysis would require acquisition of numerous data points. In this case, a means for data storage and retrieval would be required.
Once the tissue measurement characteristic is evaluated in steps 64 a–d, the evaluation is used as a basis, as stated above, to determine transmurality in step 66. Upon an indication of transmurality the ablation process is stopped in step 68. At this point, if more ablation lesions are desired as part of a long continuous lesion path, the ablation instrument 26 is moved to facilitate the creation of additional lesions. The assessment instrument 20 is placed as described herein and a new assessment is performed on the one or more additional lesions.
Referring also to
The impedance ZT measurement is then evaluated in the step 64. More specifically, as depicted in
It should be apparent that the determination of the 'constant measurement' may be predetermined as being something other than equal, with respect to previous measurements. For example, when the impedance change is noted to be within a certain limit, the change in value may be deemed constant. Additionally, the sampling time associated with the assessment loop steps 62, 64, and 66 may any suitable time, preferably to minimize the time in assessing transmurality. Alternatively, the assessment loop sampling time may be directly proportional to the acquired assessment value itself, the change in impedance for example. When a large change in value is observed, less sampling is required, and when there is a small change in value observed the sampling rate may be increased to better determine the exact time of transmurality.
Referring also to
For example, the two or more sensors 31 may be configured to passively measure the electrical impedance therebetween. This measurement can be made using any suitable method, simple utilization of a standard ohmmeter for example. However, as described in more detail above, the configuration of
The source signal VS may be any suitable passive voltage at a frequency of at least 100 khz, preferably five volts ac at a frequency of at least 100 khz, more preferably, at a frequency from about 400 khz to about 450 khz. It is important to note that the source may be selected to also carry out the ablation process as well as provide excitation for the tissue characteristic measurement. The signal generating source or power source S may be any suitable source providing the desired voltages at the desired frequencies, such as a standard function generator readily available from Hewlett-Packard Company of Palo Alto, Calif., for example.
With reference now to
With the electrode 31 b positioned within a chamber of the heart, the blood provides a conductive median for acquisition of the voltage measurement Vm, as described above. Shaft 40 a may be constructed from any suitable material consistent with the modality utilized during the ablation procedures and measurements made as part of the methods of transmurality assessment, as described herein. Shaft 40 a may be flexible, malleable or bendable, or rigid. Perturbations created by oscillatory movement of shaft 40 a relative the second tissue surface 25 may be filtered, as stated above.
Now referring to
As shown, plurality of sensors 31 a are mounted to the external surface of assembly 39 using any suitable means discussed herein, such as crimping, imbedding or epoxy bonding. At each lesion 21, 21′, 21″, a corresponding sensor 31 a, 31 a′, 31 a″ assists with the transmurality assessment related to that lesion. Therefore, as should be readily understood, the plurality of sensors 31 a, 31 a′, 31 a″, may each be selectively connected to the signal source in order to assess transmurality for a particular lesion 21, 21′, 21″, in a manner as disclosed herein.
One significant application of the present invention is in the treatment of medically refractory atrial fibrillation of the heart. For example, as represented in
For instance, using this technique, the pulmonary veins may be electrically isolated from other tissues of the heart. In particular, the strategic positioning of the ablation lesions (not shown) cooperates to create a predetermined conduction pathway between a sinoatrial node and an atrioventricular node of the heart. Further, this procedure may be performed during open or minimally invasive surgical procedures. In the latter procedure, the heart may be beating or arrested.
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Owner name: AFX INC., CALIFORNIA
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text:
I have the following XML:
<ns2:Person name="John" age="20" />
And I want to unmarshal it to JAXB object Person which was generated from the XSD.
this is the code I'm running:
JAXBContext context = JAXBContext.newInstance(PersoEntity.class);
Unmarshaller um = context.createUnmarshaller();
StringReader sr = new StringReader(xml);
Person p = (Person)um.unmarshal(sr);
Surprisingly I get the following exception:
- with linked exception:
[org.xml.sax.SAXParseException: The prefix "ns2" for element "ns2:Person" is not bound.]
How do I solve it? Thanks

subset: commoncrawl


text:
|Marc Savard texting Claude Julien pointers from afar
|05.01.11 at 3:11 pm ET
PHILADELPHIA — There's been no sign of Marc Savard since he sat at a podium, choked up, as general manager Peter Chiarelli announced the center's season was finished on Feb. 7 at TD Garden. The 33-year-old returned to his home in Peterborough, Ontario, and since then, neither Bruins fans nor the media have heard a peep from the center. They've heard about him, as he reportedly has dealt with memory issues, but have gotten nothing from the horse's mouth.
On Sunday, Claude Julien touched on the contact that he's had with Savard since he was shut down due to post-concussion syndrome. Text-messaging has kept the two in touch, with Savard even trying to help his boss call the shots at times.
"I've been texting back and forth with Marc, no doubt. For me personally, there's the player and then there's the individual. I care for him as an individual and I really hope that he gets better for the ask of his personal life," Julien said after Sunday's practice. "I've been texting to see how he's doing, and every once in a while I've said, 'I thought you were going to text me to give me some tips on certain parts of our game.' As soon as I opened that door, he took advantage of it. I've gotten a few tips from him."
One area in which Savard should be instructing Julien is the power play. The B's are 0-for-26 thus far in the postseason, and Julien admitted Sunday that the unit's performance might not be so bleak if they still had a healthy Savard.
"He was a guy that did such a good job on the power play," Julien said. "We definitely miss him there, and that's not a big secret. The way he was just poised and playing those areas, where to move the puck, it certainly created some awareness for the other team. They knew how dangerous he was. That's a part where, yeah, we lost that part when we lost Marc Savard. It's not a part that's easily replaceable.
"Somehow we've got to find a way to improve our power play without Marc Savard. It's been a challenge, but even Marc this year was not as good a player as he was before that major injury of his, and I still remember the first few years I had him. You couldn't have asked for a better power play guy. When you lose a guy like that, you're losing a real good player and a real good piece of your power play."
|No suspension for Andrew Ference after hit on Jeff Halpern
|04.28.11 at 12:49 pm ET
Bruins general manager Peter Chiarelli told reporters Thursday that defenseman Andrew Ference will not be suspended for his collision with Canadiens forward Jeff Halpern in the third period of Boston's 4-3 overtime win over Montreal Wednesday.
Halpern went down hard after hitting the shoulder of Ference in the Bruins' zone, and it was reported following the game that Ference would have a phone hearing with the league at 11 a.m. on Thursday.
Ference had two hearings with the league during the series. He was fined $2,500 for giving Canadiens fans the middle finger after scoring in Game 4.
|As Bruins power play struggles, Tomas Kaberle still trying to 'prove why I'm here'
|04.24.11 at 1:20 pm ET
Tomas Kaberle was supposed to be the answer for Boston's power play. So far, there's just been more questions in what has been an ugly tryout for a new contract.
Seemingly destined to don the black and gold eventually, the Bruins finally acquired the heavily sought-after free agent-to-be 10 days prior to the trade deadline. Since then, the Bruins' power play has been almost unfathomably unproductive. With just seven goals in 80 opportunities, the unit has been clicking just eight percent of the time. Even general manager Peter Chiarelli said recently that the team expected more out of the defenseman when they sent a first-round pick and highly touted prospect Joe Colborne to Toronto in exchange for the veteran defenseman. Chiarelli isn't the only one hoping Kaberle can pick it up.
"I always put a lot of pressure on myself," Kaberle said Sunday at TD Garden. "Hopefully I can prove why I'm here. I would like to help with every little thing I can do on the ice. Obviously, I am one of the guys on the PP, and it would be nice to be something going there."
Kaberle had nine points for the Bruins in his 24 regular season contests since being acquired, but as the spotlight grew brighter with the arrival of the playoffs, the 33-year-old had an ugly showing. He reversed a puck too hard in the Bruins' zone, making for an easy Scott Gomez pass to Brian Gionta to set up what would be the game-winning goal.
From there, things didn't improve as much as they needed to. Kaberle had major struggles in Game 2, displaying an inability to keep the puck in the zone on routine plays, a suggestion that perhaps he may have been pressing. If a turnaround is to be made, perhaps the defenseman can build on the fact that things have at least been looking up statistically. He's had an assist in each of the last two games, and with how bad things were in Games 1 and 2, it's a starting point.
"I felt like the first couple of games I could have been better," Kaberle admitted Sunday. "The last few games, I've felt a lot better, and I'm feeling better confidence-wise. I'll take it from there."
Right now, any signs of confidence from Kaberle should be a good thing, as his play — despite making the as-advertised passes — has not been a major game-changer for the B's in the postseason. He still isn't producing on the man advantage, and his now-infamous fakes on the power play aren't fooling anybody. Fairly or unfairly, Chiarelli's move to get Kaberle will be seen as a major steal by the Leafs unless the power play starts getting the results that have eluded them for too long. There's no better way to do that than to get the power play going, but teammates won't let all the responsibility fall on Kaberle.
"I'm sure he feels pressure just like all of us," Dennis Seidenberg said Sunday. "It's not just him that wants to do better. I think it's everybody that wants to create and wants to get that advantage you're supposed to get. Right now it's just not working, and I'm sure he thinks as much as everybody else about it — what he can do, and what we should do improve it. I guess it's a work in progress."
A first-round pick and a former first-round center with as high a ceiling as Colborne's is not something a team wants to give up for a player that can help the power play be a "work in progress." That type of package is reserved for a star player, and that's clearly what the Bruins thought they were getting. There's still time for Kaberle to justify the move and prove that the trade for a puck-moving defenseman was more than an asset-moving blunder, but for now the waiting game continues.
|Peter Chiarelli 'relatively satisfied' with Tyler Seguin's development
|04.11.11 at 3:53 pm ET
Rookie Tyler Seguin was among the topics discussed in Bruins general manager Peter Chiarelli's conference call with the media on Monday. Seguin played in 73 games as a rookie, totaling 11 goals and 11 assists for 22 points. He was a healthy scratch eight times, but Chiarelli noted that having him spend the year back in Plymouth (OHL) would not have helped anyone.
"I'm relatively satisfied with the development," Chiarelli said. "You have to put it in the context of his age and put it in the context of he's an individual who I think has seen that he has to grow in certain areas on and off the ice. He's a real good kid."
Daniel Paille's four goals over his last games has made it safe to assume Seguin will be a healthy scratch when the playoffs begin Thursday, but Chiarelli didn't rule out the idea of the 19-year-old finding his way into the lineup before all is said and done.
"My guess is that he won't start in the lineup for the playoffs. I hope that he finds his way into it. The play is going to ramp up in the playoffs," Chiarelli said. "Had he gone back to juniors, the areas where he had to get better would have been left dormant and so he had to play this year and face those areas head on. A terrifically talented kid with speed, he has to learn to make these plays that he can do and we've seen these plays all the time. So I'm relatively satisfied. Tyler is a good kid and he's going to get better."
Chiarelli admitting that Seguin is unlikely to be in the lineup Thursday shouldn't come as a major surprise, as the combination of Paille's impressive play to close out the season and Seguin's inconsistencies made things pretty predictable.
Though Seguin did get to play in 73 games, his leash was clearly shorter than it would have been had he played for a non-playoff team. As a result, the combination of his raw talents, struggles with physical play and limited ice time left him 22nd in scoring amongst rookies this season.
The more interesting point is Chiarelli pointing out that sending Seguin back to juniors would not have benefitted the youngster. It makes sense, as Seguin's dominant play for Plymouth in his draft year (48+58=106), suggests that he probably wouldn't have taken it upon himself to become a more physical player, as he could get results without it.
Just how Seguin could end up finding his way into the lineup remains to be seen. At face value, it seems it would take an injury to a forward or detrimental play from Paille.
|Having made their moves, B's making noise on the ice, stay quiet on deadline day
|03.01.11 at 2:44 am ET
It was a generally quiet couple of days leading up the NHL trade deadline throughout the league, but with the way the Bruins have been going, they may not have been a team that needed much more via trade.
The B's had their biggest day in that department 10 days prior to the deadline. Seemingly in an effort to both upgrade the roster quickly and avoid taking chances at the last second, general manager Peter Chiarelli made a couple of big deals on Feb. 18, reeling in Tomas Kaberle from Toronto and a package of Rich Peverley and (less notably) Boris Valabik from Atlanta. With the team having already acquired center Chris Kelly from the Senators earlier in that week, Chiarelli hinted at the post-Kaberle trade press conference that he was done making big deals.
With less than $1 million in cap space, you probably should have seen that coming.
Even so, the trade deadline passed, and the B's moves leading up to it consisted of the following:
– Signing Shane Hnidy
– Trading Brian McGrattan and Sean Zimmerman to the Ducks for David Laliberte and Stefan Chaput, a deal that involved only AHL players.
– Trading Jeff Penner and Mikko Lehtonen's rights to the Wild for Swedish goaltender Anton Khudobin.
Not exactly moves that scream "difference-maker," huh? Well, they don't have to when they also scream "the team's already made its moves."
With Kaberle, Peverley, and Kelly already in the fold, the Bruins were able to use the days leading up to the deadline as a bonding experience while on a Canadian road-trip. While other teams were adding pieces, the Bruins' new pieces were already contributing. Boston has won five straight, including all four since Kaberle came on board.
While much of the discussion following the trade deadline is on how a team with improvements in tow will fare in the offseason, the moves or lack of moves also mean big things for the stretch run of the regular season. It seems that's another area in which the B's might be aided. Already with a six-point lead over the Canadiens in the division despite having played one game less than the Habs this season, the fact that the Canadiens were also quiet over the last couple of days is also encouraging for the B's. The Habs made their biggest deal when they brought in James Wisniewski from the Islanders earlier in the season, and their lack of activity at the deadline is something the B's will take.
|Peter Chiarelli: Bruins aim to re-sign Tomas Kaberle
|02.18.11 at 5:07 pm ET
Bruins general manager Peter Chiarelli spoke Friday at TD Garden to discuss a busy day in which he made two trades. The Bruins moved Blake Wheeler and Mark Stuart to the Thrashers earlier in the day in exchange for Rich Peverley and Boris Valabik before sending Joe Colborne, the Bruins' first-round selection in the coming draft, and a conditional pick to Toronto in exchange for Tomas Kaberle.
"It's a strong message to our team, to our fans that we want to win and we want to be successful," Chiarelli said Friday.
Kaberle has long been rumored as a potential trade target for the Bruins. In 58 games with this season, the 32-year-old Czech blueliner has three goals and 35 assists for 38 points.
"We felt that we needed a player like Tomas," Chiarelli said. "A player with good vision, a good skater who can quarterback a power play, has played many games in the league. A very smart, heady player who can skate."
Kaberle had to waive his no-trade clause to facilitate the deal to Boston, and will be a free agent at season's end. Given the steep price the B's had to pay in Colborne, the 16th overall pick in the 2008 NHL draft, Chiarelli is hopeful that Kaberle will prove to be more than a rental.
"I looked upon this trade as we looked upon the [Dennis] Seidenberg trade. He's a guy that you want to re-sign," the GM said. "Having the time of when you acquire him to the time you sign him, it gives a little flavor of the player and how he fits in the group.
"Of course there's a chance that we won't re-sign him, but I want to re-sign him. We want to re-sign him. I've had some brief discussions with Rick Curran, his agent, and nothing is forthcoming. Nothing will be forthcoming until after the season, but I've had a good history with Rick and the Orr hockey group. I think it would smooth sailing to sign him when it comes to that time. It's an important part of this deal because we're giving up significant assets."
Chiarelli noted that given the deals for Kaberle and Peverley, in addition to Tuesday's trade for Ottawa center Chris Kelly, he believes that as far as big deals go, the Bruins should be quiet leading up to Feb. 28's trade deadline.
"If I do anything else, it will be something very small unless something significant is available and fits," he said. "For the most part, we're done."
|Peter Chiarelli transcript from Chris Kelly trade press conference
|02.16.11 at 4:03 am ET
Thanks to the awesome folks at the Bruins, here is the complete transcript of the press conference Bruins general manager Peter Chiarelli held Tuesday night following the trade of Chris Kelly:
Opening Statement'¦
So you've obviously seen the release. We've acquired Chris Kelly in a deal this evening in return for our own second round pick in this coming Entry Draft. Chris is a two-way center, he's'¦ I don't know if he's 30 or 31, he's a late-eighty [November 11, 1980]. He has a lot of playoff experience, very good on faceoffs, he's a high character person. He plays both ways and he can'¦ we needed a centerman that is going to give us some depth. Chris can give us that and he can play up and down the lineup also. I've obviously had a connection to him in my time in Ottawa, and know him as a person. He's a very good person, has good leadership characteristics. He's under contract for next year, also. And we're happy to have him in the organization. He's going to help us.
On how important it was to get a player who wasn't going to be just a rental'¦
When you go out into the market and there's rentals, there's good things and bad things to rentals. The bad thing is you don't know if you'll be able to resign them. So with Chris [Kelly], you have him for at least another year which is a good thing. His market price is set. And he's a known commodity in the sense that I know him, our scouts know him, having seen him a lot in the East. There's also good things to rentals, meaning contracts who are expiring so it gives you flexibility for the summer. But we think this is a good thing in light of we're not'¦we have a lot of uncertainty with Marc Savard. So this helps us in that sense too. And he can play the wing too. He's a smart player and a responsible player. He can play up the middle and he can play the wing. But he's a natural centerman.
On if when the team lost Marc Savard, he had in his mind that he wanted to find another centerman or if he waited to see how things played out'¦
Well you look at all your'¦all of the options come up at once in your mind. So like oh we've got some young centermen, we've got whether it's Tyler [Seguin], whether it's Zach [Hamill], whether it's Joe Colborne, those are three off the top of my head. You instantly'¦as a manager you know what the market is anyways so you automatically run through the couple of names in your head. You talk to your scouts, you see'¦we saw Zach play a bit. And actually I thought he did pretty well. And I think Tyler had a strong game in Detroit and he's'¦the fact that Chris can play the wing also, his versatility is very helpful too. So he was available, he brought a good two-way game and he can make plays also and we felt that we had to make a move on him.
On if there is another move on the horizon'¦
Well I've been pretty public in saying I'd like to get a defenseman, so that's still in the works.
On if the move for a defenseman is close'¦
Well I know there's a lot of furor here today. But I've had discussions on a number of fronts and I'd say a couple of them are closer, but I don't have anything imminent. Read the rest of this entry »


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Osteoporosis Health Center
Bone-Building Drugs May Also Beef Up Cartilage
June 15, 2001 -- A drug being developed to prevent the breakdown of bone caused by a type of cancer may also be able to prevent or slow the deterioration of cartilage in joints, a condition that can lead to painful and disabling osteoarthritis and rheumatoid arthritis, report French researchers in a small study published in the May issue of the journal Bone.
In a study of 26 patients with Paget's disease of bone, a disorder marked by breakdown of bone and abnormal attempts by the body to repair it, the drug Zometa appeared to at least partially prevent the deterioration of type II collagen, the protein that is the primary component of cartilage in joints.
Their findings suggest that Zometa and similar drugs used to treat osteoporosis and related conditions may also have a protective effect on cartilage in general, say Patrick Garnero, MD, and colleagues with the French National Institute of Health and Medical Research.
Zometa belongs to a class of drugs known as bisphosphonates, which includes the FDA-approved osteoporosis drugs Actonel and Fosamax; Zometa has not been approved for either osteoporosis or Paget's disease but may be in the near future, according to a spokesperson for the Paget Foundation. Currently, its intended purpose is the aforementioned treatment of a condition brought about by cancer that has spread to bones.
Throughout life, new bone is constantly being formed by cells called osteoblasts; the bone-building action is balanced by bone breakdown or "resorption," which is performed by another class of cells called osteoclasts. Paget's disease and osteoporosis are caused by an imbalance in the bone formation/breakdown cycle. Bisphosphonates help to preserve bone by interfering with the action of osteoclasts, thereby allowing a more normal bone growth pattern to occur.
Because studies of bisphosphonates in animals had suggested that the drugs could also have an effect on the formation of joint tissues, Garnero and colleagues looked for evidence of a similar effect on cartilage in humans. They looked for signs of type II collagen destruction in the urine of 26 patients with Paget's disease and a comparison group, both before and after a single injection of either Zometa or a placebo.


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PREVIEWS: "Daredevil," "Uncanny X-Men," & More Marvel Comics On Sale August 3, 2016
Comic Books
Showing results 1-2 of 2
Savage Dragon #200
"Savage Dragon" #200 has plenty of exactly what readers have come to expect from Erik Larsen, which covers quite a large range of content and character.
|December 10th, 2014
DCU Halloween Special 2009 #1
Continuing a DCU tradition, this issue features a bunch of fan favorite characters celebrating the Halloween season. The efforts put forth for the stories contained in this issue -- as well as the results -- are mixed.
|October 27th, 2009


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Small Business
PC Connection delivers a full range of specialized small business IT services and solutions with dedicated support
Offering a full range of business technology solutions and services, from design through deployment
MoreDirect offers enterprise clients complete tech solutions and innovative tools to streamline IT procurement
Government & Education
GovConnection fulfills the technology needs of academic and government institutions with specialized IT solutions
As an Authorized Apple Reseller, MacConnection offers new release priority access, custom configurations, and more
Plasma Televisions
Plasma televisions are the ideal communications solution for a wide array of business needs. Restaurants use them to keep patrons up-to-date with current news, and sports bars use them to provide entertainment with football, basketball and soccer games. Often, companies will also use plasma televisions for...


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22 Sep 2011 8:25 PM #1
Unanswered: Using Eclipse for Developing ExtGWT Applications
Hi All,
I am new to Eclipse and extGWT.
I have found a link - http://www.sencha.com/learn/getting-...-with-ext-gwt/
it helps in basic config of eclipse, I followed all the steps and then after testing the simple hello world app, I tried my hands on basic grid example available through http://www.sencha.com/products/extgwt/examples/. I created a new project with the name SimpleGrid and copied all the code available on the examples page onto my java file under client package.
I did face some issues like unresolved -
import com.extjs.gxt.samples.resources.client.Resources;
import com.extjs.gxt.samples.resources.client.TestData;
import com.extjs.gxt.samples.resources.client.model.Stock;
For these, I copied entire source files under resources folder (that comes
under gxt-2.2.5/samples/resources/src/com/extjs/gxt/samples) into src folder of my eclipse app.
After all these exercises, when I tried to run the project, in the console it gives following error -
Loading modules
[ERROR] Unable to find 'org/sample/SimpleGrid.gwt.xml' on your classpath; could be a typo, or maybe you forgot to include a classpath entry for source?
[ERROR] shell failed in doStartup method
As mentioned earlier, SimpleGrid is my project name and also is the name of java file under client package, which I modified to have basic grid code. From where this has come up, can some one help in resolving this?
I would also like to request for more detailed steps (with examples) on the same with database connectivity and features including advanced ExtJS widgets.
Thanks in advance.
26 Sep 2011 7:56 PM #2
I would appreciate if some one could reply to my queries.
Thanks and Regards
27 Sep 2011 12:51 PM #3
- Join Date
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- Minnesota
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Regarding your setup issues: Did you get the basic GWT hello world to work before adding GXT to the project? What version of GWT are you using, and are you using the Google Plugin for Eclipse to run? The GXT widgets and controls are based off of the GWT toolkit, so if a basic GWT project doesnt work, GXT cannot work. Other getting started examples are available at http://code.google.com/webtoolkit/usingeclipse.html
Ext GWT is related to Ext JS only in name, and in basic scope - no Ext JS widgets can be used with Ext GWT.
As far as database connectivity goes, the same basic rules for building standard J2EE servlets apply to GWT. We encourage developers to use GWT's RPC (see http://code.google.com/webtoolkit/do...unication.html) to communicate with their Java-based servers, and there are examples in the samples you looked at as to how to set that up. Many users have many different ways of talking to their backend database, using such systems as JPA, Hibernate, or even directly making SQL requests - any of these can be used to get data, and return it through a RPC servlet.
3 Oct 2011 3:11 AM #4


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2 Reviews
These are so very yummy. Because my husband must eat Gluten Free, we used Jules flour instead of wheat and I lessened the sugar to 1 tbl, and they were just fabulous with homemade soup for dinner and with eggs for breakfast.
Yum! This was a very nice side for my homemade hunter's chili! I liked it's texture better than recipes that don't use masa. Thanks for the great recipe!


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- WebMD Physician Directory of Grand Island Doctors
- Grand Island Emergency Contacts
- Nearby Grand Island Hospitals
- Find a Local Pharmacy on RxList - Grand Island
Grand Island Doctors and Specialists for Dog Bite Treatment
Dog Bite (Treatment)
Dog bite facts
- Dog bites account for more than 90% of all animal bites. 4.5 million dog bites occur each year in the U.S., and more than 30,000 victims require reconstructive surgery.
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Emergency Contact for Grand Island
- In case of Emergency, call 911
Nearby Grand Island Hospitals results
- 1Saint Francis Medical Center
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- 8Henderson Healthcare Services
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Andrew Lloyd Webber's Evita at the Pantages
* Additional fees apply. No coupon or promo codes necessary to enjoy the displayed discount price.
The last date listed for Evita was Sunday November 10, 2013 / 1:00pm.
Currently at Hollywood Pantages
Roundabout Theatre Company's Cabaret -- The Dark, Decadent Hit Broadway Musical
- Full Price:
- $65.00 - $85.00
- Our Price:
- $39.00
Step out of the modern world and into the glittering underworld of pre-WWII Berlin to join the fun… More
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Featured review from Goldstar Member
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Evita is a very strong show and this company provided a pretty strong performance of it. It was well-staged and the singing was generally good. As with many of the touring casts, though, there just seemed to be a *little* something lacking. Overall, a good evening out. Our seats were good and everything regarding Goldstar went seamlessly.
star this review starred report as inappropriate
Great show! I can't believe that I finally got to see it.
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It fell flat for me. The voices and staging were good but it was too dark for my taste.
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A wonderful theatrical experience. I thought it was an all around strong production. The voices and the technical aspects of the show were superb! Strong Lead Performers and ensemble. A true muscial theatre classic in the historical Pantages.


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Andechs Monastery
Tours & Tickets
Page: 1
Private Tour: Munich Sightseeing Including Andechs Monastery
Famous for its beautiful architecture and Bavarian charm, and renowned for its annual Oktoberfest, Munich has much to offer any visitor. On this private ... Read more
Location: Munich, Germany
Duration: 5 hours (approx.)
Page: 1


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Easily manage the merging and compression of js and css files from plugins and themes
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early morning - the peak is highlighted by sun - that's where we will be in about 5hours - looking at it from this point I just cannot believe it is where we will be :)
no more picture will be taken till we reach the summit ... have to keep up with good pace...
the last step to reach the summit :)
stocking up calories for the way down ...
views from the top
this is it - the summit! - 14,005 ft above the sea level this time!
happy moment!
Notch Mountain
Mt. of Holy Cross - 14,005 ft
views of Angelica Couloir
on the way back - looking up at the talus
walking down the boulder field
left the talus - next goal - descent over the boulder field
more views of the Angelica Couloir
looking down the Angelica Couloir again - it is a North Face - there is still snow here
East Cross Creek is fed by Lake Patricia high at 11,398 feet
looking back at the peak - still cannot believe we did it!
descending boulder field - looking back at the peak
a beautiful meadow up in the mountains - it is above the creek valley
amazing rock! it is a painting engraved in stone! use your imagination about what you see there! it reminded me a Yellowstone valleys with bison herds grazing there! :)
last peek at the peak! - the boulder field is finally left behind...
still a long-long way down ...
finally climbed from the East Cross Creek valley (10,700ft), back on the way to the Half Moon Pass - views of the peak from here are amazing! you can see the entire trail over the ridge to the summit!


text:
Sugar coma.
Brendan had just fallen down - hard - but got up without a whimper and was dusting himself off.
And then he's off.
The boys were taking a bath while I put Calista to bed. When I came out of her room, they were nowhere to be found. Finally I spotted them outside. Only one of them had bothered to get dressed. I can't share the best pictures.


text: Exactly what I needed this plugin to do. I only give it 4 stars instead of 5 because I hoped it would support "multiple" images per taxonomy record, but it only supports 1 image per taxonomy record. It would be great to associate more than 1 image to a category, for example.