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Location: Mississippi, Alabama, and Tennessee
Webpage: National Park
General Description: The Natchez Trace Parkway is an All-American Road that travels 444 miles from Natchez, Mississippi to Nashville, Tennessee passing through the northwest corner of Alabama on the way. It roughly follows the old Natchez Trace creating a greenway from the southern Appalachian foothills of Tennessee to the river bluffs of the lower Mississippi. The Natchez Trace dates back many centuries beginning as Indian paths between the villages of the Natchez, Choctaw, and Chickasaw Indians. As the United States expanded westward in the late 1700s and early 1800s, growing numbers of travelers created new paths that interconnected the old Indian trails and the Natchez Trace slowly became a well traveled trail. Understanding the need for a mail delivery through the "southwest wilderness" that was Mississippi, President Jefferson in 1801 designated the Trace a national post road between Nashville and Natchez. In the early 1800s through the mid -1820s, "Kaintucks" from the Ohio River Valley floated cash crops, livestock, and other goods down the Ohio and Mississippi River to New Orleans in wooden flatboats. Since it was not possible to take these boats back upstream they would be broken down and sold for lumber and the farmers would begin the long walk or ride back to their homes laden with money and good for the trip. As the road was improved, "stands" or inns provided lodging, food, and supplies to the Trace travelers. As steam power became common along the Mississippi and Ohio rivers in the 1820s, this use of the Trace dramatically declined. Much of the Trace cut through land controlled by the Natchez, Choctaw, and Chickasaw Indians which under many treaties limited the efforts to settle the land along the Trace until the Chickasaw Indians were removed to Oklahoma in the 1930s. Consequently, no major towns grew up along the Trace and it mostly fell into disuse by the Civil War. Some sections of the Trace would be used during this war for movement of supplies and troops and the Trace played a role in the Battle of Brices Crossroad and Battle of Tupelo in 1864. Establishment of the Parkway was initiated by Congressman Busby of Mississippi along with the Daughters of the American Revolution who began planting markers and monuments along the old Trace in the 1930s. In 1934, President Roosevelt ordered a survey of the proposed Parkway in 1938 with construction beginning in 1939. The last two sections of the Parkway, the bypass of Jackson, Mississippi and the southern terminus in Natchez were finally completed in 2005. The Parkway crosses four distinct ecosystems and eight major watersheds. It is the habitat for 1500 species of plants, 33 mammal species, 134 bird species, and 70 species of reptiles and amphibians.
1) There are over 100 markers and historical sites along the 444 miles of the Trace and it will take us multiple days along the Trace to visit them all. Therefore, our experiences along the Trace will be in the order that we visited them, along with the mile-marker from the southern end of the Trace. In general, the Trace is a very nice way to travel this part of the country for a number of reasons. First, there is very little traffic on the Trace for most of the year and since the speed limit is 50 mph, there is a leisurely pace. Second, there are no signposts and limited signage along the road cutting down on the clutter, Third, access is generally limited and controlled so there are no stoplights or stopsigns to interrupt the trip and no cross traffic to deal with. Fourth, the Parkway extends an average of 800 feet in width, so most of the time you are traveling through woods with limited views of buildings. Finally, the frequent stops for historic or natural landmarks are a great way to experience Mississippi and Tennessee.
2) Owl Creek Mounds – Milepost 243.1 Located 3 mile west of the Parkway on the Tombigbee National Forest, the Owl Creek Mounds is an important Indian ceremonial site. The site was originally composed of five Indian mounds, a central plaza, and village site. The mounds have been dated from 800 to 900 years ago as part of the Mississippian culture. The site was occupied for only around 100 years, which is short for this era. Today only 3 mounds remain of the original site.
3) Chickasaw Agency – Milepost 241.4 The Government Agency that oversaw Indian relations with the Chickasaw Indians from 1801-1825 was located near this location along the Trace. There is nothing to see here except for the interpretive sign.
4) Witch Dance – Milepost 233.2 This location commemorates the Indian tradition of the Witch Dance. Tradition holds that witches would gather for nighttime ceremonies in this area. During their ceremony, the grass would wither and die where they danced with nothing growing there again. You can still see these barren patches on the ground today. Today this location is the site of a bike-in campground and the trailhead for one of the horse trails.
5) Bynum Mounds – Milepost 232.4 These mounds were built between 1800 and 2050 years ago during the Woodland era. The two remaining mounds were part of a 6-mound complex used for ceremonial purposes. The mounds began as burial mounds and used for ceremonial purposes. Today there is a covered exhibit at the site and a short path to the two remaining mounds.
6) Old Trace – Milepost 221.4 Along here is a good section of the Old Trace in a sunken road bed as the trace approaches a small creek. There are steps leading down into the sunken roadbed and you can take a short hike in both directions along the trace.
7) Line Creek – Milepost 213.3 Although the Indians did not "own" land in the same sense as the European settlers, they did recognize and honor traditional boundaries between the tribes. Line Creek was traditionally the boundary between the Choctaw and Chickasaw Indian tribes. There is nothing other than an interpretive sign at this location where you can view Line Creek. where it crosses under the Pathway.
8) Pigeon Roost – Milepost 203.5 This is a former roosting area for millions of passenger pigeons, that would darken the sky in their day, but are now extinct. There is nothing other than an interpretive sign at this location.
9) Ballard Creek – Milepost 201.3 A picnic area set aside for motorists along the Pathway.
10) Old Trace – Milepost 198.6 Another location where the original Trace crosses the modern Pathway. Along with the interpretive sign, you can take a short walk along the original trace back to a dirt road.
11) Jeff Busby – Milepost 193.1 There is a short drive up a surprising hill to one of Mississippi's highest points at 603 feet. It is amazing you can see no evidence of this hill from the Pathway, however the views from the top are nice. Along with a picnic area, there is also a camping area for RVs with some nice pull-through sites, although there are no water or electrical hookups, so it is strictly dry camping.
12) French Camp – Milepost 180.7 Site of present day town of French Camp and also near the location of Louis LeFleur's stand or inn along the trace. Along with the interpretive sign along the Pathway, there is also the small town of French Camp with cafes and Visitor Center.
13) Hernando de Soto – Milepost 243.3 The Spanish explorer Hernando de Soto spent the winter of 1540-1541 nearby, although the exact location is not known. Today there is nothing more than an interpretive sign (which was missing when we were there) at this location.
14) Monroe Mission – Milepost 245.6 Northeast of this location was the Monroe Mission built in 1822 to provide an education and Christianity to the Chickasaw Indians. By 1827, 100 acres were under cultivation and 81 children were attending the School. Although many of the leaders of the Chickasaw tribe were educated at one of the three missions along the trace, they were short lived as the Indians were removed from the area in the 1830s. Today there is nothing but the interpretive sign at this location.
15) Tockshish – Milepost 249.6 Site of the stand (inn) and midway point on the 1800s Post Road, where post riders would transfer mailbags and horses. Today there is nothing except the interpretive sign at this location.
16) Chickasaw Council House – Milepost 251.1 Near this location was the site of Pontatok, the Chickasaw Nation capital in the 1820s. This was the location where the Pontatok treaty was signed in 1832 where the Chickasaw agreed to sell their remaining lands to the US Government and relocate to land in Oklahoma. Today there is nothing except the interpretive sign at this location on the Pathway.
17) Black Belt Overlook – Milepost 251.9 This marks the northwestern extent of the Black Belt, which is a vast prairie that extends east and south through Alabama. The area is known for its rich, black soil and used extensively for the production of cotton before the Civil War. As this area was under the control of the Chickasaw Indians until the 1830s, it was never extensively farmed. The overlook provides a nice view of the surrounding landscape to the west.
18) Chickasaw Village Site – Milepost 261.8 With a small parking lot situated just off the Parkway, this area provides information about a typical Chickasaw Village. There are covered exhibits about the Indian culture and living conditions. On the ground they have laid out paving stones to show the outline of winter and summer quarters, as well as, a wooden stockade that would be used for defensive purposes when attacked. There is a short nature trail at this site with interpretive signs giving information about the uses the Indians made of the various trees and shrubs from the viewpoint of a young Indian child. This also the terminus of a hiking trail that runs north 4 miles to the Visitor Center running close to the Pathway.
19) Old Town Overlook – Milepost 263.9 From this location you can see Old Town Creek and its floodplain alongside of which was located the Chickasaw village known as Old Town. This was one of the main villages of the Chickasaw Nation. Today there are a couple of interpretive signs and views of the creek.
20) Parkway Visitor Center and Headquarters – Milepost 266.0 This an excellent location to gather information about the Parkway including its history, culture, and natural features that can be seen all along the Parkway. There is a very good 20 minute video about the Parkway as well. The exhibits are very well done providing a lot of information about everything that can be seen along the Pathway.
21) Confederate Gravesites and Old Trace – Milepost 269.4 Up a short path from the pull-out is the location of 13 unidentified Confederate soldiers that died along the trace. It is not known if they were survivors of the Battle of Shiloh or died from the Brices Crossroads or Tupelo battles. In fact, they may have died due to illnesses at any time during the Civil War as the Confederate soldiers moved along the Trace.
22) Tennessee-Tombigbee Waterway and Jamie L. Whitten Bridge – Milepost 293.2 The Trace crosses over the Tenn-Tom Waterway at this point using the bridge named for the Congressman that acquired funding for both the waterway and the trace. The pullout goes down to the edge of the waterway where you get a good view of the canal just below a dam and lock system.
23) Pharr Mounds – Milepost 286.7 There is a series of 7 burial mounds from 1800-2000 years ago stretched out over 200 yards. There is a nice interpretive center, restrooms, and picnic tables as well at this location. Unfortunately, there is not a path to the mounds, so you can only view them from a distance. They do keep the area going back to the mounds mowed, so they are easily seen.
24) Donivan Slough – Milepost 283.3 Along with an interpretive sign about the importance of wetland sloughs, there is a short walk in between the two channels of the slough. Along the path are numerous interpretive signs about the trees and slough ecosystem.
25) Twentymile Bottom Overlook – Milepost 278.4 From this vantage point you get a view of the Old Trace where it enters the lowlands to the north known as Twentymile Bottom.
26) Dogwood Valley – Milepost 275.2 Along the Old Trace this small valley was known as Dogwood Valley due to its many large dogwood trees. Part of the short trail through one end of the valley is along the Old Trace. While there are a lot of large, old dogwood trees, I was disappointed that the dogwood trees had bloomed early this year. We visited in early April, but there were few of the trees still in bloom.
27) Cave Spring – Milepost 308.4 This is a natural cave that was probably used by American Indians for water and stone. It is difficult to tell how deep the caves might be, but since they are primarily sinkholes in the limestone formations, they are likely very shallow.
28) Bear Creek Mound – Milepost 308.8 A single flat top mound from the Mississippian Culture built 1400-1600 years ago along Bear Creek.
29) Freedom Hills Overlook – Milepost 317 A moderately steep quarter-mile, paved trail leads up to an overlook at the highest point on the Trace in Alabama at 800 feet. Unfortunately, they don't want the remove the pine trees bordering the trace down below the overlook, so the view is very limited from the overlook.
30) Buzzard Roost Spring – Milepost 320.3 This is the site of an historic stand (inn) along the Trace operated by Levi Colbert, a renown Chickasaw Chief of mixed blood. In addition to the site of the stand there is a short trail down to the spring used for water.
31) Colbert Ferry – Milepost 327.3 This is the site of another historic stand along the Trace and was operated by George Colbert, another renowned Chickasaw Chief and businessman. Down the bluff to the Tennessee River was the location of the ferry that was essential for the Kaintucks traveling the Trace every year, as well as, US troops under the command of General Andrew Jackson during the War of 1812.
32) John Coffee Memorial Bridge – Milepost 328.6 The pullout area is on the north side of the Tennessee River with an interpretive sign about the forced removal of the Chickasaw and Choctaw Indians in the 1830s. If you are lucky, as we were, you might see a barge traveling the River.
33) Rock Spring – Milepost 330.2 A half mile loop trail takes visitors around the edge of an old beaver pond formed from the water flowing out of rock spring. There are multiple interpretive signs along the trail about the wetland ecosystem created by the pond.
34) Cypress Creek picnic area – Milepost 343.5 A very nice picnic area along the Trace with picnic tables along the edge of Cypress Creek. Cypress Creek is a clear water creek flowing over rocks that make a nice environment for lunch.
35) Meriwether Lewis Milepost 385.9 – This is the gravesite of Meriwether Lewis who died here in 1809, just a few years after returning from the Lewis and Clark Expedition. At the time he was the new Territorial Governor of Louisiana and traveling the Trace on his way to Washington, D.C. It is not clear whether he was murdered for some unknown reason or committed suicide. This is one of the main locations along the Parkway and such has a large campground area, picnic area, and hiking trails. For example, there is a mile long foot trail along the Old Trace as it travels along the ridge before descending to cross Little Swan Creek.
36) Metal Ford Milepost 382.8 – A short drive from where the Parkway crosses the Buffalo River, is the ford where the Old Trace crosses. It was called the Metal Ford because the river flows over a smooth rock shelf which was like crossing on a metal bridge. This also the location of an old iron furnace where you can walk along the sunken mill race dug for the furnace.
37) Napier Mine Milepost 381.8 – This is the site of a large pit iron mine that was in operation until the 1930s. While natural vegetation is beginning to cover the old pit, it is still an extensive and impressive hole in the ground.
38) Old Trace Drive Milepost 375.8 – This is a one-way (north bound only) 2.5 mile paved drive along the Old Trace with multiple pull-outs for scenic views of the surrounding valley. Beware that although it is paved, there are some sharp turns with trees on both sides that can be tricky for large vehicles.
39) Dogwood Mudhole Milepost 367.3 – This location serves as an example of the surrounding terrain, which although being located along a ridge, would become extremely muddy and impassable at times to wagons after heavy rains. The Old Trace is actually located about a mile to the south of this location.
40) Sweetwater Branch Milepost 363 – A nice short nature trail along the Sweetwater Branch with spring wildflowers in full bloom.
41) McGlamery Stand Milepost 352.9 – Site of the one of the old stands or inns along the Trace in the mid-1800s.
42) Sunken Trace Milepost 350.5 – At this location you can see 3 separate slightly sunken roadbeds next to each other. Serves as an example how they would bypass mudholes.
43) Phosphate Mine Milepost 390.7 – A short walk by a historic phosphate mining site. With the road construction while we were there, this site was not accessible.
44) Fall Hollow Milepost 391.9 – A short walk to the top of the falls that gives the location its name. After viewing the falls from above there is a steep trail that leads to the base of the falls.
45) Swan View Overlook Milepost 392.5 – Potentially a nice scenic view overlooking Little Swan Creek. However, the growth of the trees have severely limited the view.
46) Old Trace Milepost 397.4 – This was the boundary with the Chickasaw Nation after they had ceded land to the US in 1805 and 1816 before finally being forced to relocate to Oklahoma in the 1830s. At this location the Old Trace was actually the boundary.
47) Sheboss Place Milepost 400.2 – The location of one of the stands used by travelers in the 1800s. The name of the place came from the owners, the wife being Scottish and the husband a Chickasaw Indian. Not speaking English, the husband would refer all inquiries to his wife by saying "She boss".
48) Tobacco Farm/Old Trace Drive Milepost 401.4 – Exhibits including an old tobacco barn, providing information about the use of the area before the federal government bought the land for the Parkway. This is also the beginning of a two mile drive along the Old Trace. It is a narrow, one-way (north bound only) dirt road that gives a good feel of traveling on the Trace.
49) Old Trace Milepost 403.7 – A 2,000 foot preserved section of the Trace that is perfect for a short hike.
50) Jackson Falls Milepost 404.7 – A short hike to the falls. Although the path is cement, but warned that it is a steep hike. However, it is the only way to see the falls which cannot be seen from the parking lot. This fall is interesting since it is a recent addition, geologically speaking, as Jackson Creek no longer follows its original valley, but wore a hole through the limestone creating this "new" path to the Duck River.
51) Baker Bluff Overlook Milepost 405.1 – A nice view of the Duck River and farmland along the river.
52) Gorden House Historic Site Milepost 407.7 – Site of the early 1800s trading post, inn, and ferry across the Duck River along the Trace. At the time this was the fanciest home in the area and signaled those traveling north on the Trace that they would soon be in Nashville. The house dates from 1818, but is no longer open to the public. A hike leads down to the location of the ferry across the Duck River.
53) Water Valley Overlook Milepost 411.8 – Another nice scenic view of the surrounding valleys.
54) Tennessee Valley Divide Milepost 423.9 – This is known as the Tennessee Valley Divide since this ridge separates the watersheds of the Tennessee and Cumberland Rivers. In 1796 it was the original boundary between the new state of Tennessee and the Chickasaw Nation, before they began ceding their lands beginning in 1805.
55) War of 1812 Memorial Milepost 426.3 – This memorial was placed along the Old Trace to commemorate its importance to General Andrew Jackson during the War of 1812. Multiple times he used the Trace to move his soldiers to and from New Orleans and the Gulf Coast.
56) Garrison Creek Milepost 427.6 – This picnic area was named for a nearby 1801-02 US Army Post.
57) Birdsong Hollow Milepost 438 – There is an overlook of the Double Arch Bridge over TN 96 that won the 1995 Presidential Award for Design Excellence. Spanning the Parkway across the valley hundreds of feet above the valley floor. Obviously, this and the remainder of the Parkway heading north is one of the latest additions to the Parkway. Truly an impressive bridge.
58) Norther Terminus Milepost 444 – While the end of the Parkway at TN 100, this was not the true end of the trace which is miles east of this location and still over 20 miles from entering the town of Nashville at that time. There is really nothing to see at the terminus, except as a nice location to turn around.


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Dropping in to catch everybody up. I'm still working on cleaning out the brew basement. Of course that "little" oven problem I mentioned is getting more attention than the brewing related projects. Also looking to brew soon. It'll probably be with dry yeast. The theme will be cheap ingredients that I already have in stock. Shortly after that beer is ready to drink I'll be demonstrating extract brewing on Teach a Friend to Brew day.
Of course Fermentation Friday is afoot tomorrow over at Final Gravity. I'm going to write about what I hope to brew with indigenous ingredients, rather than what I've actually brewed which is nothing.
I've witnessed lots of pumpkin beer and Oktoberfest beer at the taps lately. T.J.'s in Paoli PA is having a big Oktoberfest celebration. They even sell liters! How cool is that? I just might stop in this weekend. Of course there's a ton of things going on this month. I rely on Bryan at The Brew Lounge to keep me up to date on Southeastern PA events and beyond.
The Joe's Ancient Orange Cinnamon Clove Mead we're making is just about ready to be tasted. That ought to be interesting. One week to go.
That's all for now. Hope things are going well out there in homebrew ...er beer land.

subset: commoncrawl


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In this super informal episode my BFF of almost 30 years Reem joins me as my co-host! If you love celeb gossip and reality TV as much as we do you're going to want to tune in!
Topics include the latest Kardashian news like KKW's newest perfume bottle pictured below, a Jersey Shore cast member scandal and our opinions on this seasons Big Brother Canada!
Click below to listen!


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I was looking for a particular piece of fabric when I came across the pictured piece of work. It consists of scraps felted to a piece of green felt using the embellishing machine.
I intend to add some bling and make something amazing - well I hope that I am inspired to make something with it!
I have finished some of the pieces for my "Road to my house" wall hanging. I have decided to put this aside now so I can do some sewing for Christmas.
Oh and my camera had a lovely rest and is talking to me again.
Technology - it is quite beyond me but I am pleased that I don't need to make any decision about a new camera just now.


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This was published 1 year ago
Band-Aid solution not enough to fix My Health Record
So federal Health Minister Greg Hunt has finally heeded a chorus of criticism by lawyers, doctors and information specialists about the My Health Record scheme, promising to strengthen privacy provisions and legislate to ensure government agencies can only access information with a court order.
But his very belated recognition of fundamental deficiencies in the design and implementation of a billion dollar e-health scheme is disquieting. While we can be glad that he has at last recognised problems, his proposal to fix those problems is inadequate. Applying Band-Aids at midnight is not good medicine and not good policy.
Critics of the scheme will be looking for meaningful change and for official responsibility, rather than Hunt's sorry attempt to blame deficiencies on the previous Labor government. Hunt and his predecessor, Peter Dutton, have been in power for some time. An effort to blame the legislation on the ALP is disingenuous. It doesn't provide much confidence that changes to the legislation will be more than superficial.
The scheme has been defective from the beginning, with little effort by any of the ministers to heed criticism or look at lessons from overseas. In Britain, the Caldicott report damned the design and implementation of that nation's e-health system, pointing to inadequate identification of risk and mitigation of it. Caldicott highlighted the dangers of disregarding privacy concerns and being indifferent to health consumers through a mandatory opt-out arrangement.
Proponents of the Australian scheme have emphasised there are safeguards. You can trust the government, they say ... and the several hundred thousand people who potentially have access to your health data. Last month's major data breach in Singapore's e-health scheme – not that different to My Health Record – might induce some caution.
Proponents have also claimed there will be meaningful enforcement if something does go wrong. Privacy specialists question that claim. The Office of the Australian Information Commissioner – the national privacy watchdog – lacks resources and a proactive culture. The office languished on death row for more than a year after then attorney-general George Brandis indicated it was unnecessary. It is significant that the commissioner was very late in acknowledging concerns by doctors and other My Health Record critics. Can we trust a watchdog that has trouble getting out of its kennel and is scared to bark at the hand that feeds it? Once health data has been breached it will not come back, irrespective of who whistles.
As a society we should be asking who is responsible for My Health Record. We must ensure mistakes don't recur. We need more than tweaks to defective security settings. We need more than a last-minute fix – previously seen as unnecessary – that would prevent a large number of agencies gaining access to your records simply by asking. It's time for a thorough review of the legislation, the system design and its operators.
I teach health, privacy and consumer protection law and I am enthusiastic about a best practice national e-health system. My Health Record is not it. We need to rethink the scheme.
Bruce Baer Arnold is an assistant professor of law at the University of Canberra.


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I have been representing an Army Captain who came up hot on a urinalysis for THC. He swore he had no idea how it happened, and we did some digging. Turns out he had been to a music festival in Atlanta. When he got home there was a batch of cookies on the kitchen table that his roommate had left there. You guessed it. One of his roommate's friends had made "special cookies" and my client unwittingly ingested them. We got statements from the roommate, the "baker" and one other. My client accepted adjudication at Article 15, where the CG found him not guilty of the charge of wrongful use of marijuana. My client starts law school in the fall, so this is a great result for him.
Recent Accomplishments
By William Cassara | April 15, 2020


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Take Your Money Out of the Bank, While You Still Can
Dave Hodges
Activist Post.com
Tuesday, April 2, 2013
It is now clear, the government of Cyprus was given two options by the IMF and the EU in which they were told that they could steal money from private bank accounts or they could leave the Eurozone all together and face total economic annihilation. This theft involves seizing the funds of all accounts over 100,000 euros, then stealing up to 40% of those funds sometime over the next few weeks, or whenever EU finance ministers decide exactly how much to steal.
However, no accounts containing less than 100,000 euros will be impacted. This amount was not arbitrarily chosen. The 100,000 mark was chosen because all EU bank accounts are insured up to 100,000 euros. Therefore, the criminal banksters believe that they can steal anything over 100,000 euros because it is not insured.
Except for the 132 preferred insiders who got their money out of Cyprus the day before the announcement of the grand banking theft, the Eurogroup finance ministers have subsequently announced that the large Bank of Cyprus depositors' above the 100,000 level now have their accounts frozen. The 132 preferred insiders reminds me of Goldman Sachs doing a put option for preferred insiders in Transocean stock the morning of the Gulf oil explosion.
Lars Christensen, the CEO of Saxo Bank, in a recent blog post, chastised the thievery of the IMF and the EU with the following statement.
This is a breach of fundamental property rights, dictated to a small country by foreign powers and it must make every bank depositor in Europe shiver. Although the representatives at the bailout press conference tried to present this as a one-off, they were not willing to rule out similar measures elsewhere – not that it would have mattered much as the trust is gone anyway. It is now difficult to expect any kind of limitation to what measures the Troika and EU might take when the crisis really starts to bite.
The Rest…HERE


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The 17th Annual Sunflowers for Wishes at Buttonwood Farm in Griswold will be in full bloom from July 18th through July 26th!
More than 450,000 sunflowers are expected to bloom on fifteen acres of farm land yielding sunflower bouquets that will be sold to benefit Make-A-Wish Connecticut. Also returning to the farm this year will be the Buttonwood Farm hayrides through the sunflowers, bringing joy and happiness to everyone who visits.
Duane Button and his family donate one hundred percent of the proceeds to Make-A-Wish® Connecticut, to create wishes for local children battling life-threatening medical conditions. Sunflower-themed t-shirts and note cards will also be offered to help support Make-A-Wish.
"We are proud and honored to have Duane and the entire Button family as part of the Make-A-Wish family here in Connecticut," says Diana Maynard, Events Manager for Make-A-Wish Connecticut. "Thanks to people like the Buttons, countless wishes have been granted for 16 incredible years, and over $1.2 million in donations!"
And don't forget to purchase one of Buttonwood's own famous sunflower ice cream cones, made right there on the farm!
For more information on "Sunflowers for Wishes," please call (860) 376-4081 or visit www.sunflowersforwishes.com.
To volunteer at Sunflowers for Wishes, contact Stefanie Richardson, Community Relations Manager, at firstname.lastname@example.com.
We will see you at the farm!
Donate your airline miles to help wishes take flight!
Join our email list!
Stay connected to Make-A-Wish Connecticut.


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By: Associated Press
October 11, 2019
MIAMI, Fla. (AP) -- U.S. Rep. Matt Gaetz is demanding an end to the impeachment inquiry against President Donald Trump.
The conservative Florida lawmaker told a crowd of dozens outside of Democratic U.S. Rep. Donna Shalala's Miami-area office that Republicans will "fight for Donald Trump" and do all that they can to prevent impeachment.
Gaetz criticized Shalala, calling her and several other Florida House Democrats who have supported moving forward with the inquiry hypocritical. He says they're so caught up in investigations and impeachment that they've forgotten about their constituents.
The showing is part of a multimillion-dollar Republican National Committee-sponsored campaign designed to rally public support against the possible impeachment of the president.
Shalala's staffers say the congresswoman wasn't at her office at the time of rally.


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For the 4th year of this match, the youngest of the Varsity Blind Wine-Tastings, we returned to The Porter in Bath. We were also joined once more by experienced judges, Aidan Bell of DBM Wines and Gareth Birchley of Berry Bros & Rudd.
James Clark had arranged a number of training sessions with both universities, and was pleased to see that enthusiasm for the discipline of Blind Wine-Tasting was increasing at both institutions. Furthermore, the level of knowledge and understanding had vastly improved. The 4th annual year of this match certainly felt as though it marked a turning point; the competition is now well established and this hopefully marks the beginning of a tradition to rival the 63 years of the Oxford and Cambridge match!
We had selected 6 white wines and 6 red wines, all of which were served 'blind' to the 7 competitors from both Bath and Bristol University. The whites proved to be the more challenging of the two flights, with an Italian Soave revealing almost nothing in terms of recognisable characteristics, and a Meursault from Joseph Drouhin boasting such tremendous depth of flavour that it pointed towards the new world rather than Burgundy. The Reds by contrast were arguably easier to identify; spice and pepper from the Rhone and bubblegum and carbonic maceration from Beaujolais. This was reflected in the scores, with both teams achieving very similar scores in the Reds, however the advantage had already been secured with the Whites, with Bath steaming ahead of their rivals and thus emerging triumphant overall.
Therefore after 4 years of the match, both teams have won 2 matches each; there is everything to play for in 2017!
Olivia Higgins was crowned the top taster and was praised by Aidan Bell for her consistency, achieving very similar marks in the whites and reds.
Following the match we enjoyed a celebratory luncheon accompanied by wines from the Pol Roger Portfolio.
We look forward to returning to Bristol for next year's match!


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I just wanted to say goodmorning to everyone. Its way too early to be awake. I am so tired I feel like my head has jumped off my shoulders and run away lol. But anyways… I don't know where all of you have gone but I really miss talking to you so whenever you get a chance give me a call. Atleast let me know your alive and well. And if you haven't called before for whatever reason it's ok don't be shy we can take it slow lol no worries. Ok well I think since I am awake I will have some Lucky Charms and then work on finding my head. hehe. I hope everyone has a great weekend and I can't wait to talk to you.
Hugs & Kisses,


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Events Listings
Berkeley This Week
"Native Plants of Yosemite" A slide show and talk with Ranger Erik at 6:30 p.m. at the Oakland Museum of California, 1000 Oak St., at 10th, Oakland. Cost is $5-$8. 238-2200.
"The Spirit of John Muir" A performance highlighting Muir's adventures in the western wilderness at 7:30 p.m. at the Oakland Museum of California, 1000 Oak St., at 10th, Oakland. Cost is $5-$8. 238-2200.
"Pint for a Pint" Blood Drive Blood donors will receive a coupon for a free pint of gelato from Gelato Classico. The blood drive will be in Conference Room A from noon to 6 p.m. at Alameda Hospital, 2070 Clinton Ave., Alameda. To schedule an appointment call Louise Nakada at 814-4362.
"The Iron Wall" A documentary with interviews with prominent Israeli and Palestinian peace activists, farmers, soldiers and political analysts at 7 p.m. at St. Joseph the Worker, 1640 Addison. Free. Sponsored by The Fr. Bill O'Donnell Social Justice Committee. 499-0537.
International Working Class Film Festival with "Maquilapolis," "My Bicycle," "No Te Rajas," and Estamos Aqui" at 7:30 p.m. at Humanist Hall, 390 27th St., Oakland. Suggested donation $5. www.HumanistHall.net
Estacio Libre and Collectiva Zapatista Ramona Film Fest at 7:30 p.m. at AK Press, 674-A 23rd St., Oakland. 208-1700.
Bayswater Book Club meets at 6:30 p.m. at Barnes and Noble Coffe Shop, El Cerrito Plaza. 433-2911.
Free Diabetes Screening Come find out if you might have diabetes with our free screening test and make sure not to eat or drink anything for 8 hours beforehand, from 8:45 to 1:30 a.m. at the Downtown Oakland Senior Center, 200 Grand Ave. 981-5332.
Berkeley Women in Black weekly vigil from noon to 1 p.m. at Bancroft and Telegraph. Our focus is human rights in Palestine. 548-6310.
Circle Dancing, simple folk dancing with instruction at 7:30 p.m. at Finnish Brotherhood Hall, 1970 Chestnut St at University. Donation of $5 requested. 528-4253.
Oakland Heritage Alliance Neighborhood Walking Tour of the F.M. "Borax" Smith Estate from 10 a.m. to noon. Meets at the redwood tree, corner of McKinley Ave. and Home Place East. Tickets are $10-$15. email@example.com
Walking Tour of Old Oakland around Preservation Park to see Victorian architecture. Meet at 10 a.m. in front of Preservation Park at 13th St. and MLK, Jr. Way. Tour lasts 90 minutes. Reservations can be made by calling 238-3234.
Canyonero Hike A three-mile hike across habitats up to Wildcat Park, from 10:30 a.m. to 1:30 p.m. Led by Meg Platt, naturalist. For information and meeting place, call 525-2233.
Bicycle Trip Along the Hayward Shoreline Meet at 8:30 p.m. at San Leandro Marina Park for a 14-mile round trip excursion, partly paved. Bicycle helmet required. Bring bicycle lock, lunch and liquids. For information email email@example.com
"Ice Scone" Benefit for Save Berkeley Iceland, at the Cheese Board, 1504 Shattuck Ave. All proceeds from the sale of this special scone will go to saving the family-friendly community center for ice skating. 599-4591. www.SaveBerkeleyIceland.org
Artists Funding the Arts Silent Auction to benefit the SF AIDS Foundation. Bidding begins at 10 a.m. at 4th St. Studio, 1717D 4th St. Bidding closes Sunday at 8 p.m. 527-0600.
Kensington Police Department Program for ages 3 and up at 2 p.m. at the Kensington Library, 61 Arlington Ave. 524-3043.
"Brainiacs" An interactive neural anatomy lesson, at 1 p.m. for ages 7 and under, 2:10 p.m. for 8 and older at Hall of Health, 2230 Shattuck Ave., Lower Level. Cost is $5, no one turned away. 705-8527.
Community Festival at The Way Christian Center with music, health and college fairs, and activities for children, from noon to 4 p.m. at 1222 University Ave. Free. 848-2117.
Preschool Storytime for 3 to 5-year-olds at 11 a.m. at the Albany Library, 1247 Marin Ave. 526-3720 ext. 17.
Free Garden Tours at Regional Parks Botanic Garden Sat. and Sun. at 2 pm. Regional Parks Botanic Garden, Tilden Park. Call to confirm. 841-8732.
Around the World Tour of Plants at 1:30 p.m., Thurs., Sat. and Sun. at UC Botanical Garden, 200 Centennial Drive. 643-2755.
The Berkeley Lawn Bowling Club provides free instruction at 10:30 a.m. at 2270 Acton St. 841-2174.
Car Wash Benefit for Options Recovery Services of Berkeley, held every Sat. from 9 a.m. to 2 p.m. at the Lutheran Church, 1744 University Ave. 666-9552.
People's Park Community Workshop on the future design and programs for People's Park, at 1 p.m. at First Church of Christ Scientist, 2619 Dwight Way. Pre-registration required. RSVP to 415-288-3390. email@example.com
Oakland Heritage Alliance Neighborhood Walking Tour of the Mountain View Cemetary from 10 a.m. to 12:30 p.m. Meet at Chapel of the Chimes, 4400 Piedmont Ave. Tickets are $10-$15. firstname.lastname@example.com
"Open Garden" Join the Little Farm gardener for composting, planting, watering and reaping the rewards of our work, from 2 to 4 p.m. at Tilden Nature Area, Tilden Park. 525-2233.
"Green Sunday" Upholding Our Rights to a Healthy Community A discussion on the California Healthy Communities Network and how its work affects our community, at 5 p.m. at the Niebyl-Proctor Library, 6501 Telegraph Ave. at 65th in North Oakland.
Solo Sierrans Walk to Explore the Albany Bulb and discover the unique works of art here. Meet at 2:30 p.m. at the entrance of the Bulb at Buchanan St. and I-80. Optional dinner afterwards. RSVP to Therese at 841-5493.
"Park Life" Martial arts, nutritional education, peer counseling, and healthy snacks for at-risk and overweight youth of all ages at 3 p.m. at Ohlone Park, bordering Hearst, between California and Sacramento. Donation requested, no one turned away. 684-1668.
Berry Tasting from 10 a.m. to 2 p.m. at Kensington Farmers' Market, 303 Arlington, behind ACE Hardware, Kensington.
Family Day at the Magnes Museum, including tours of current exhibitions, at 11 a.m. at 2911 Russell St. 549-6950.
Social Action Forum with Jacques Verduun on programs offered inside San Quentin Prison at 9:30 a.m. at Unitarian Universalist Church of Berkeley, One Lawson Rd., Kensington. 525-0302.
Free Hands-on Bicycle Clinic Learn how to keep your bike in excellent working condition through safety inspections, from 10 to 11 a.m. at REI, 1338 San Pablo Ave. 527-4140.
Free Garden Tours at Regional Parks Botanic Garden in Tilden Park Sat. and Sun. at 2 p.m. Call to confirm. 841-8732.
Tibetan Buddhism with Betty Cook on "King Ashoka: An Ancient Model of Buddhist Social Responsibility" at 6 p.m. at the Tibetan Nyingma Institute, 1815 Highland Pl. 843-6812.
Red Cross Blood Drive from 10 a.m. to 4 p.m. at the West Pauley Ballroom, MLK Student Union, UC Campus. To schedule an appointment go to www.BeADonor.com (Code: UCB).
Berkeley CopWatch organizational meeting at 8 p.m. at 2022 Blake St. Join us to work on current issues around police misconduct. Volunteers needed. For information call 548-0425.
Bus Rapid Transit: Focus on Downtown Berkeley Community Workshop at the Transit Subcommittee meeting of the Transportation Commission at 6:30 p.m. at the North Berkeley Senior Center. 981-7010.
Tuesday Documentaries at 7 p.m. at the Gaia Arts Center, 2120 Allston Way. Donation of $5 benefits the Berkeley Food and Housing Project. 665-0305.
Baby-friendly Book Club Bring your baby, and your love of books at 10 a.m. at the Kensington Library, 61 Arlington Ave., Kensington. 524-3043.
Tuesday Tilden Walkers Join a few slowpoke seniors at 9:30 a.m. in the parking lot near the Little Farm for an hour or two walk. 215-7672, 524-9992.
Fresh Produce Stand at San Pablo Park from 3 to 6 p.m. in the Frances Albrier Community Center. Sponsored by the Ecology Center's Farm Fresh Choice. 848-1704. www.ecologycenter.org
Red Cross Blood Drive from 10 a.m. to 4 p.m. at Brandywine Realty, 2101 Webster St., Ste. 600, Oakland. To schedule an appointment go to www.BeADonor.com (Code: BRANDYWINEREALTY)
Free Diabetes Screening Come find out if you might have diabetes with our free screening test and make sure not to eat or drink anything for 8 hours beforehand, from 8:45 to 1:30 a.m. at the Downtown Oakland Senior Center, 200 Grand Ave. 981-5332.
Community Sing-a-Long every Tues, at 2 p.m. at the Albany Senior Center, 1247 Marin Ave. 524-9122.
Family Storytime for preschoolers and up at 7 p.m. at the Kensington Library, 61 Arlington Ave. 524-3043.
Berkeley Camera Club meets at 7:30 p.m., at the Northbrae Community Church, 941 The Alameda. Share your digital images, slides and prints and learn what other photographers are doing. Monthly field trips. 548-3991. www.berkeleycameraclub.org
St. John's Prime Timers meets at 9:30 a.m. at St. John's Presbyterian Church, 2727 College Ave. We offer ongoing classes in exercise and creative arts, and always welcome new members over 50. 845-6830.
South Berkeley Assessment of Library Needs with Noll & Tam Architects who have been hired to investigate possible spaces for the library at the Ed Roberts Campus, at Board of Library Trustees meeting at 7 p.m. at South Branch Library, 1901 Russell Street at MLK, Jr., Way. 981-6107.
Walking Tour of Old Oakland uptown to the Lake to discover Art Deco landmarks. Meet at 10 a.m. in front of the Paramount Theater at 2025 Broadway. Tour lasts 90 minutes. Reservations can be made by calling 238-3234.
A Talk with Al Haber, the founder of S.D.S. will speak of the reformed S.D.S. as well as a history of Berkeley's Long Haul and doing peace work in Israel/Palestine at 7 p.m. at the Lonh Haul, 3124 Shattuck Ave. www.thelonghaul.org
"Tani O, Who Are You?" with Nigerian Chief Priest Elebuibon Akinyemi on Ifa wisdom at 7 p.m. at La Peña. Cost is $10. 849-2568. www.lapena.org
Walk Berkeley for Seniors meets every Wednesday at 9:30 a.m. at the Sea Breeze Market, just west of the I-80 overpass. Everyone is welcome, wear comfortable shoes and a warm hat. 548-9840.
Berkeley Peace Walk and Vigil at the Berkeley BART Station, corner of Shattuck and Center. Sing for Peace at 6:30 p.m. followed by Peace Walk at 7 p.m. www.
Red Cross Blood Drive from 9 a.m. to 2:30 p.m. in the Samuel Merritt Bechtel Room, 400 Hawthorne St., Oakland. To schedule and appointment go to www.BeADonor.com (Code: SMC)
CoHousing Slide Show on cohousing principles and the new cohousing development in Grass Valley, at 7 p.m. at 1250 Addison St, Suite 113. 849-2063.
Adult Self-Protection Workshop on everyday safety skills from 10 a.m. to noon in Berkeley. Cost is $105, no one turned away. Location details upon registration. 831-426-4407.
Cope with Creativity Workshop on "Write to Connect with Grief" at 6:30 p.m. at 4401 Howe St., Oakland. To register call 888-755-7855, ext. 4241.
World of Plants Tours Thurs., Sat. and Sun. at 1:30 p.m. at the UC Botanical Garden, 200 Centennial Drive. Cost is $5. 643-2755. http://botanicalgarden.berkeley.edu


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One of the most solemn and numerous divine services took place in St.Catherine Cathedral. Metropolitan of Yekaterinodar and Kuban Isidore held the Divine Liturgy. The Governor of Kuban Veniamin Kondratiev and the Mayor of Krasnodar Evgeny Pervyshov together with parishioners kept vigil at night.
"In these holy and saving days of God, I wish all of you to enjoy the spiritual feast of the Great Christmas Holiday. Keep the peace, love among yourselves, be faithful in words and deeds, perform honestly Christian and civic duty, be tolerant and indulgent," addressed to parishioners metropolitan Isidore.
Several thousand citizens and guests of the regional center came to keep vigil in St.Catherine Cathedral. On the night from January 6th to 7th in Krasnodar festive Christmas services were held in churches, cathedrals and chapels of 49 Orthodox parishes.
The Nativity of Christ is one of the main Christian holidays. In the church calendar Christmas is followed by Christmastide, which lasts 12 days before the Eve of Theophany. During this time festive events will be held in the Orthodox parishes of Krasnodar.
Read the news of Krasnodar in our channel Telegram


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GOLDEN Square's players had to dig really deep in a desperate last quarter at the Gardiner Reserve to hold off a fired-up Gisborne. Continue reading
Monthly Archives: July 2017
Royals keep hopes alive while Lions lead the way
WAFL round 19… Continue reading
Civilian craft of all sizes cross the Channel by Richard Jones
A look at Dunkirk (PG)
IT'S May 1940 and hundreds of thousands of British soldiers are trapped on the beaches of Dunkirk in France. Continue reading
Tigers snatch a one-game break over Dragons by Richard Jones
KYNETON weathered a third quarter challenge from Sandhurst to win Saturday's massive Showgrounds feature match by 21 points. Continue reading
Thunder mirror Dockers in strange WA footy week
WAFL round 18… Continue reading
Emily's devotion to her craft of poetry by Richard Jones
A look at A Quiet Passion (PG)
EMILY Dickinson's genius as a writer and poet was only recognised some decades after her untimely death at 56 during the mid-1880s. Continue reading
Bennell and Bulldog comebacks highlight WAFL
WAFL round 17


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ZetaClear In Taiwan
All of these people and finally fall off. But before you have diabetes nail thickening and reduced anxiety. My toenails have been clear eversince. Magnifying Glass A brilliant guy thought of having either of the fungal infection of the toenail. So usually it is necessary. When the feet can be treated with this trend where… Read More »


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Welcome to The Hummingbird Centre
Yes we're still open. Some appointments are Telehealth only, and face-to-face is still available with some of our clinicians.
Please read our COVID policy.
Read how Telehealth works.
Directed by local Psychologists Dr Rickie Elliot and Alikki Russell, The Hummingbird Centre is comprised of a team of Psychologists, Social Workers, Occupational Therapists, Yoga Teachers and Administrative Support staff who help adults, children, teenagers and families to create positive changes in their lives.
We are passionate and down-to-earth independent practitioners who collaborate to provide high quality psychological interventions that are client-centred, goal-oriented, and holistic for everyone from infancy to adulthood.
We provide services from multiple locations across Newcastle and Lake Macquarie to provide greater access to services for our clients, including Warners Bay, Redhead and Broadmeadow.
In ancient cultures, the hummingbird represents courage, joy, love, present moment awareness, endurance, infinite possibilities, and healing from negativity. This unique bird reminds us to let our true colours shine and that life's sweetest nectar comes from within.
Our therapists are trained in a variety of assessments and therapeutic approaches to support clients to achieve their goals and are able to tailor treatments to suit their clients needs.
At The Hummingbird Centre, all of our clinicians are trauma and attachment - informed practitioners. In addition to traditional talk-therapies, we provide additional services such as group programs, Neurofeedback, The Safe and Sound Protocol (SSP), Eye Movement Desensitisation and Reprocessing (EMDR), Trauma Sensitive Trauma Centre Yoga (TCTSY), Attachment Therapy, Parenting Support, and Dialectical Behaviour Therapy (DBT).
Our Directors coordinate and provide a multitude of professional development opportunities for clinicians within our team and within the community to encourage collaboration and support between clinicians and reduce the time and costs associated with travelling away for training.
Podcast: Rickie Elliott discusses how to avoid COVID Overwhelm
March 2020
Alikki Russell interviews Kathy Steele on Dissociation
July 2019
Dr Rickie - Guest speaker on Mel Sarge's podcast "How to build self-esteem in your kids"
May 15th, 2019
Mother Jumpers
11th November 2018
Dr Rickie jumped out of a plane with Mel "Sarge" Seargant to raise awareness for Perinatal Anxiety and Depression as part of COPE's Mother Jumpers fundraiser.
The Newcastle Herald wrote about the important message behind the jump - read more.


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Transcatheter Tricuspid Valve Implantation of NaviGate Bioprosthesis in a Preclinical Model
Author + information
- Received August 15, 2017
- Accepted August 25, 2017
- Published online February 26, 2018.
Article Versions
- previous version (January 24, 2018 - 11:00).
- You are viewing the most recent version of this article.
Author Information
- Jose L. Navia, MDa,∗ (naviaj{at}ccf.org),
- Samir Kapadia, MDb,
- Haytham Elgharably, MDa,
- Gabriel Maluenda, MDc,
- Krzysztof Bartuś, MDd,
- Cristian Baeza, MDc,
- Rajesh K. Nair, MDe,
- Josep Rodés-Cabau, MDf,
- Cesare Beghi, MDg and
- Rodolfo C. Quijano, MD, PhDh
- aDepartment of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
- bDepartment of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
- cHospital San Borja Arriaran, Santiago, Chile
- dJagiellonian University, Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Krakow, Poland
- eDepartment of Cardiology, Waikato Hospital, Hamilton, New Zealand
- fQuebec Heart Institute and Lung Institute, Laval University, Quebec City, Quebec, Canada
- gOspedale di Circolo Polo Universitario, Varese, Italy
- hNaviGate Cardiac Structures, Inc., Lake Forest, California
- ↵∗Address for correspondence:
Dr. José L. Navia, Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, 9500 Euclid Avenue/Desk J4-1, Cleveland, Ohio 44143.
Visual Abstract
• Surgery for isolated tricuspid regurgitation carries a high mortality risk, especially in the setting of right ventricular dysfunction and reoperation.
• Transcatheter valve therapy is as promising alternative for treatment of isolated tricuspid valve disease associated with right heart failure.
• The NaviGate bioprosthesis is a novel self-expanding valved stent designed to treat functional tricuspid regurgitation.
• The preclinical evaluation shows that transcatheter tricuspid valve implantation using the NaviGate device is safe, is feasible through 2 different approaches, and results in a secure and stable engagement of the native annulus, with excellent hemodynamic and valve performance.
Patients with isolated functional or recurrent tricuspid regurgitation are often denied surgery because they are considered to be at high risk. Transcatheter valve therapy provides a less invasive alternative for tricuspid regurgitation associated with right heart failure. We have evaluated the feasibility of transcatheter tricuspid valve implantation of the NaviGate valved stent in a long-term swine model. The valved stent was successfully implanted through transjugular and transatrial approaches on the beating heart with excellent hemodynamic and valve performance. No conduction disturbance or coronary obstruction was observed. This technology could provide an alternative treatment for patients who are at high surgical risk with severe tricuspid regurgitation and compromised right ventricular function.
Transcatheter valve technologies have been emerging over the past decade as a new paradigm of heart valve treatment, especially in selected high-risk patients whose care becomes increasingly challenging; these technologies include percutaneous replacement of aortic and pulmonic valves, as well as multiple techniques regarding repairing and replacing the mitral valve for functional or degenerative mitral regurgitation. Secondary tricuspid valve regurgitation (TR) is frequent in patients with long-standing left-sided valve disease, particularly in the setting of severe pulmonary hypertension and atrial fibrillation (1,2). Uncorrected, moderate, or severe TR is associated with progressive heart failure and premature death (3); even if corrected, it is a marker of lower long-term survival. However, the optimal timing and surgical technique to eliminate TR remains undefined, showing that tricuspid valve (TV) disease is not only underdiagnosed, but is also often surgically ignored. For many years it was believed that secondary TR would improve after mitral valve surgery alone, and it was consequently undertreated (4). Thus, for example, in 1967, Braunwald et al. (5) recommended conservative nonsurgical management of "functional" TR. In the 1980s, it was observed that patients who had undergone successful mitral surgery sometimes returned years later with severe symptomatic TR and right heart failure. When these patients underwent reoperation, mortality was high (3). More recently, compelling data have shown that surgically untreated secondary TR can persist or even worsen despite correction of the associated left-sided lesion (6), suggesting that due to the severity and progressive course of the disease, an aggressive approach toward secondary TR is warranted (7,8). Unfortunately, this approach is rarely used, so patients usually do not undergo TV reoperations for secondary or recurrent TR, leading to high mortality rates due to worsening right heart failure (9).
In general, most of these patients present with renal impairment, severe pulmonary hypertension, and cardiac cirrhosis late in the disease state; given their coagulopathic state and low likelihood of improvement of right ventricular (RV) function in the perioperative period, they become high-risk surgical candidates. Thereby, transcatheter approaches to TV disease could become an attractive alternative solution for these patients who present a burgeoning clinical unmet need for therapeutic advances. In addition, less invasive strategies may allow for earlier surgical treatment of TR, which may improve functional capacity and reduce end-organ dysfunction.
The NaviGate bioprosthesis (NaviGate Cardiac Structures Inc., Irvine, California) was designed exclusively to overcome the technical challenges associated with transcatheter valve implantation for these high-risk patients. Herein, we describe the preclinical feasibility study of a new transcatheter self-expanding bioprosthetic TV, implanted in a chronic porcine model using transcatheter and minimally invasive approaches on a beating heart with a sutureless valve implantation technique.
NaviGate bioprosthesis
The NaviGate atrioventricular valve is a biological valved stent; it consists of a specifically configured Nitinol alloy stent into which is mounted a trileaflet valvular mechanism fabricated from equine pericardium that has been fixed in low concentrations of buffered glutaraldehyde (Figures 1A to 1D). The configuration of the stent is specifically designed in a geometry that engages the tricuspid annulus (TA) and TV leaflets from both inferior and superior aspects and maintains a minimal extension into both the atrium and ventricle to avoid flow dynamics alterations. Thus, the inferior aspect or ventricular diameter is designed to match the dilated tricuspid annulus typical of secondary TR, which has a mean diametric dimension of 40 ± 5 mm for most patients. For this experimental study, the superior or atrial size of the valve stent is maintained at 30 mm in diameter, and the inferior or ventricular diameter at 40 mm, ensuring that transvalvular gradients will be normal for a TV (ΔPmean ≤5 mm Hg) at normal flows. This configuration results in a truncated conical shape that helps to reduce the height of the valved stent. This results in low intrusion into the right atrium (RA) and RV, giving rise to a divergent nozzle that, by slowing the flow entering the RV, reduces energy loss and flow separation to optimize the transvalvular gradient. From the surface of the truncoconal structures, specially configured structures (winglets and graspers) are incorporated into the proximal (n = 12) and distal (n = 12) ends of the stent. They are deployed sequentially at defined angles to radially fix the bioprosthesis to the TA, minimizing dislocation toward the adjacent chambers. The atrial winglets of the NaviGate device are designed to be relatively short and are covered by woven microfiber polyester fabric lining to avoid compression of the conduction fibers (Figure 1).
The preserved xenogeneic pericardial membrane is used to fashion both leaflets and inner walls of the valved stent. The lining of woven microfiber polyester fabric supports the pericardial membrane wall to protect its integrity and to prevent paravalvular leakage (PVL). When totally assembled, the bioprosthesis proceeds through a proprietary dehydration process in which all glutaraldehyde and most of its water are removed; it is then sterilized by ethylene oxide exposure and stored in its primary container in the dehydrated form until use.
Delivery system and implantation procedures
Transatrial approach
The atrioventricular valved stent is delivered transatrially through a minimally invasive right thoracotomy directly through the free wall of the RA into the TV, using a sutureless technique without cardiopulmonary bypass or rapid ventricular pacing. The delivery device is depicted in Figures 2A and 2B. It evokes the configuration of a mitral commissurotomy device of decades past; when introduced into the left atrium through a small incision, the curved shape and angulation of the shaft leads the distal end into a central alignment position in the TV. The valved stent is loaded and crimped inside the distal capsule, and it can be retracted by simple controlled turning of the proximal handle knob. Retraction causes exposure of the ventricular or distal aspect of the valved stent, causing the ventricular winglets or graspers to deploy that may capture the leaflets above the tricuspid chordae tendineae. The operator can readjust the depth and angle of the valve/delivery system using fluoroscopy and intracardiac echocardiography (ICE) to achieve a good relationship between the RV, RA, and the plane of the TV annulus for final deployment.
Details of the delivery systems and surgical transatrial implantation technique of the valve are presented in Supplemental Appendix 1.
Transjugular approach
The transjugular delivery system consists of an 80-cm usable catheter with a central conduit accommodating a 0.038-inch guidewire and a 24-F shaft reinforced with interior metallic coiling, for the most part, to optimize its tracking through the vasculature and imaging visibility. The distal section is flexible, as that includes the 30-F outer diameter stent-enclosing capsule and a mechanism that allows steering in 2 directions, including depth control by forward or reverse motion of the distal capsule when in the immediate vicinity of the TV annular plane. The introducer sheath (∼45 cm and 45-F outer diameter) has a hydrophilic coating for atraumatic insertion into the vessel. The catheter is pictured in Figures 3A and 3B. After gaining access into the RA through the right jugular with a modified Seldinger technique (viewed both by fluoroscopy and ICE), the distal end of the delivery system was positioned coaxially to the center of the swine TV, and the tricuspid valved stent was aligned with the plane of the TA. The middle annular region of the tricuspid valved stent was visible by fluoroscopy, with the distal anchors or grasper tips in the contracted or crimped state within the distal capsule. Details of the percutaneously implanted valve are presented in Supplemental Appendix 1.
Experimental design
In vivo assessment of safety
These studies were designed both to assess the safety of the NaviGate device and to obtain a partial assessment of its effectiveness in performing the designed function; the latter assessment aimed to provide sufficient safety data for the first-in-human evaluation.
Long-term in vivo study
A bioprosthesis valve replacement is intended to remain in situ for its life or the life of the patient. Thus, long-term implantation in the in vivo model was studied to preliminarily assess the continuous function and durability of the device. In the absence of a natural, practical, and cost-effective animal model of tricuspid regurgitation (TR), the healthy swine was chosen to test the safety of the device. Safety includes the proper delivery and deployment of the device with the delivery system. The effectiveness focused on assessment of the performance of the valved stent and its durability. Accordingly, complete percutaneous, transjugular access, catheter-guided implantation of a NaviGate self-expanding bioprosthesis into the native TV of healthy swine was successfully performed (n = 6; 85 to 90 kg) (Table 1).
Previously a series of 6 NaviGate tricuspid valved stents were implanted in 6 healthy swine (n = 6; 95 to 105 kg) in the TV orthotopic position for a long-term preclinical study using a minimally invasive right thoracotomy approach on a beating heart with a sutureless implantation technique (Table 2). All valve prostheses used in this study have equivalent design and fabrication methods, and they were evaluated in a pulsatile mock circulatory loop for hemodynamic performance and quality control. The long-term study also assesses the replicability of both implantation approaches, the valved stent's suitability to maintain valve function and valve hemodynamic function, durability, right ventricular outflow tract (RVOT) obstruction and coronary arteries obstruction if any, the formation of interfering pannus, procedural success and blood loss, possible calcification of biological tissue, and absence of thrombosis.
Implantation procedure
Pre-operative management
All animals received humane care in compliance with the Animal Welfare Act and Public Health Services policies, and the study protocol was approved by the Institutional Animal Care and Use Committee at the Gateway Innovation Laboratory, Shanghai, China.
The details for each of the modes of approach and anesthesia management are given in Supplemental Appendix 1. In brief, after gaining access into the RA (viewed both by fluoroscopy and ICE) through the antegrade transatrial and transjugular approach, the distal end of the delivery system was positioned coaxially with the center of the swine TV, and the tricuspid valved stent aligned with the plane of the TA. The middle annular region of the tricuspid valved stent is visible by fluoroscopy, with the distal anchors or grasper tips in the contracted or crimped state within the distal capsule. The tricuspid annular plane was defined using fluoroscopic imaging of guidewires in both the right coronary artery and left circumflex artery. Coaxiality of the stented valve to the tricuspid annulus was confirmed prior to deployment using multimodality imaging; fluoroscopic identification of the tricuspid annulus was defined by the guidewire, and positioning in the center of the annulus plane was guided by ICE.
When the operator, guided by imaging, was confident that the valved stent was coaxial in the right landing zone and ready to deploy, further turning of the proximal knob slowly retracted the capsule, allowing the expansion of the valved stent's distal perimeter to reach close to 80% of the nominal diameter. Then, the ventricular winglets or distal graspers engaged the TV leaflets. The final release was achieved with a turn of the proximal knob, that allowed the atrial anchors to deploy, and the tricuspid valved stent was delivered into its proper locus, anchored from the ventricular as well as from the atrial aspects of the native TV (Figure 4). No rapid pacing was required during this operation as the device functions during a slow controlled release when it reaches 60% of its opening diameter. Thus, there was no obstruction of the blood flow or hemodynamic compromise. Details of the percutaneously and surgically implanted valve are presented in Supplemental Appendix 1.
Post-deployment measurements and management
RV angiography was performed to confirm proper placement of the valve and to rule out RVOT obstruction and/or TR (central to paravalvular regurgitation based on echocardiography guidelines [10]), and a coronary artery angiogram was performed to rule out coronary artery obstruction or compression. Both transesophageal echocardiogram and ICE were used to confirm placement and proper valve function. Echocardiography, hemodynamic interrogations, and valve function assessment were repeated after 20 min when hemodynamic stability was achieved. When hemostasis was ensured, chest, neck, and femoral incisions were closed in layers in the usual fashion. The animals recovered in the acute care unit after the procedure. All animals were followed clinically for manifestation of heart failure and with serial echocardiogram assessment. All animals underwent post-mortem examination of the device and cardiac tissues. Echocardiographic assessment was performed in all animals before euthanasia as well as at 3 and 6 months for live animals. Details of the post-implant measurements and management are presented in Supplemental Appendix 2.
Data analysis
Hemodynamic measurements after NaviGate stented valve implantation were summarized using standard descriptive statistics and are reported as mean ± SD. Analysis of data was performed using a paired Student t test with 2-sided comparisons. A p value of 0.05 was considered to indicate statistical significance. Data analysis was performed using a statistical software package (SPSS for Windows, version 15.0, IBM, Armonk, New York).
Long-term study: transatrial access
Long-term transcatheter RA access of an orthotopic tricuspid valve implantation was performed in the swine model (n = 6; 95 to 105 kg) (≥25 post-operative days). All valves were successfully implanted with no technical difficulties during prostheses deployment, providing a 100% procedural success. Although the deployment was feasible for the novel valved stent, the use of a well-known minimally invasive RA access under direct vision with a sutureless implantation technique provided an advantage. The follow-up varied from 1 to ≥25 days per protocol. All animals but 1 survived the intervention: 1 died during the procedure after developing acute severe TR secondary to annulus-prosthesis mismatch that resulted in prosthesis RV migration. Of the remaining 5 animals, 1 animal survived 30 days and was sacrificed per protocol; 2 animals survived 150 days and were sacrificed per protocol; and 2 animals are still alive. No animals that survived the procedure died secondary to a cardiac or noncardiac complication. Echocardiographic and fluoroscopic assessment confirmed excellent function of the new TV in all animals, with accurate alignment and secure anchoring of the valved stent onto the TA (Figures 4 and 5). Conformance to the tricuspid annulus with no PVL or central TR was observed in 4 valves, with 1 mild PVL and 1 central severe TR/valve dislodgment. In all cases of successful implantation (n = 5) of the new valve, there was a clear unobstructed RVOT, no pericardial effusion, normal coronary artery anatomy, and no arrhythmias, with a preservation of the subvalvular apparatus. Valve function evidenced normal hemodynamic performance and normal pressure gradient across the implanted valve (≤3 mm Hg), as well as RVOT gradients (Table 3). All animals had normal RV function before the procedure and preserved RV function during follow-up period and at the time of euthanasia.
The entire procedure time in all study animals ranged from 40 to 55 min, the time from the minimally invasive right thoracotomy to position the delivery system at the TV annulus after surgical access ranged from 6 to 9 min, and the NaviGate bioprosthesis deployment time ranged from 1 to 3 min.
Long-term study: transjugular access
Long-term transcatheter right jugular access of an orthotopic tricuspid valve implantation was performed in a swine model (n = 6; 85 to 90 kg) (≥25 post-operative days). All valves were successfully implanted with a complete percutaneous approach, with no technical difficulties during prostheses deployment, providing a 100% procedural success. The delivery system's articulation feature up to 90° certainly provides an elegant mechanism to align the new valve in the center of the TA and, when combined with the guidewires' position inside of the right and circumflex coronary arteries that provides a fluoroscopic image of a horizontal plane of the TA, helps the operator secure a safe and accurate landing zone to deploy the valve on a beating heart with a sutureless implantation technique.
All 6 animals survived the intervention: 2 animals survived >210 days, 2 animals survived >120 days and are still alive, and another 2 animals survived >90 days and are both still alive. No animals that survived the procedure died secondary to cardiac or noncardiac complication. Echocardiographic and fluoroscopic assessment confirmed excellent function of the new TV in all animals, with accurate alignment and secure anchoring of the valved stent onto the TA (Figures 6 and 7). Conformance to the tricuspid annulus with no PVL or central TR was observed in 4 valves, whereas 1 animal has mild PVL and 1 animal has moderate PVL. In all 6 animals, the new NaviGate valve left a clear, unobstructed RVOT, no pericardial effusion, normal coronary artery anatomy, and no arrhythmias or atrial ventricular conduction disturbances, with a preservation of the subvalvular apparatus.
Valve function evidenced normal hemodynamic performance and normal pressure gradient across the implanted valve (≤4 mm Hg), as well as RVOT gradients (Table 3). All animals had normal RV function before the procedure and preserved RV function during the follow-up period and at the time of euthanasia.
The entire implantation procedure time in the study ranged from 45 to 60 min, the time from the percutaneous right jugular access to position the delivery system at the TV annulus ranged from 12 to 15 min, and the NaviGate bioprosthesis deployment time ranged from 1 to 3 min.
There was no significant difference between the peak gradient across the valved stent in both approaches, transatrial versus transjugular (p = 0.9), indicating feasibility for device implantation using the 2 approaches.
Euthanasia, gross necropsy, and pathology
After sacrificing the 3 animals per protocol and 1 animal that died in the operating room, a thorough autopsy was performed according to the Gateway's detailed protocols for autopsy and pathology, focusing on the biocompatibility of the devices. The heart was excised and weighed. A cursory view of the morphology at necropsy focused on reviewing the placement of the valved stent and its structure and assessment of signs of device-related trauma. A gross examination showed a proper anchoring and alignment of the valve in all animals except 1, which had a total valve dislodgment due to extreme tricuspid annulus to prosthesis mismatch. There were no signs of wear or damage to the anchoring winglets. Assessment of the chronic tissue response to the valve and anchoring mechanism valve struts and leaflets was also of particular interest; there was a normal response and normal evidence of tissue ingrowth, without thrombus formation. There was a complete circumferential seal in both sides of the stented valve without evidence of device-related trauma (Figure 8). Both the stent and valve leaflets were intact in all animals with no signs of damage.
A Faxitron x-ray cell was used to visualize the position of the valved stent within the tricuspid apparatus in the resected rinsed heart, which identified no distortion or fracture of any of the segments or stent elements in the long-term study.
Tricuspid valve disease continues to present a challenging problem to cardiovascular specialists, especially in patients who develop TR associated with RV dysfunction and right heart failure (RHF) (11,12). Recently, a more aggressive approach has been promoted for treatment of functional TR during left heart valve surgery to avoid high-risk reintervention thereafter (13–15). Patients who present for isolated TV surgery are at high risk of mortality, especially with RV dysfunction and reoperation (16–18). This could be attributed to RHF phenomena in the setting of long-standing TR that includes systemic venous congestion, volume overload, renal dysfunction, liver congestion, hypersplenism, and severe coagulopathy. Hence, many of these patients have been denied traditional open-heart surgical therapy, although the operation per se is technically less demanding than other valve surgeries.
In light of the former clinical challenges, and along with recent advances in percutaneous valve implantation techniques, the transcatheter approach stands out as a promising alternative for treatment of isolated TV disease associated with RHF. Several transcatheter techniques have been experimentally developed and tested in animal models, but few have been clinically applied in humans for treatment of TR (19): 1) transcatheter valve implantation at the vena cava level to prevent backflow of TR and decrease systemic congestion (Sapien [Edwards Lifesciences, Irvine, California] and Tric Valve [P & F Products & Features Vertriebs GmbH, Weßling, Germany]); 2) devices applied to reduce tricuspid annulus diameter (Mitralign [Mitralgin Inc., Tewksbury, Massachusetts] and TriCinch [4Tech Cardio, Galway, Ireland] devices); 3) devices applied to decrease TR volume and improve leaflet coaptation (FORMA device [Edwards Lifesciences]); 4) the Mitraclip device (Abbott Vascular, Santa Clara, California) used for edge-to-edge repair of TR; and 5) the transatrial intrapericardial tricuspid annuloplasty (TRAIPTA, National Institute of Health, Bethesda, Maryland) device (19). Regarding malfunctioning TV bioprosthesis, few groups have reported successful transcatheter valve-in-valve implantation (20,21).
All new transcatheter techniques were limited to a small number of patients who were at prohibitive risk for surgical intervention in a trial to improve their clinical symptoms and to test feasibility. Particular concerns were raised for transcatheter caval devices that include persistent right heart volume overload, RV failure, and atrial arrhythmia; however, these concerns were not evidenced on early results (22,23). The overall early and midterm outcomes showed transcatheter treatment of isolated TV disease to be feasible and promising, yet long-term follow-up as well as prospective trials are required to better evaluate the efficiency and durability of these new techniques. However, there are no reports of transcatheter valve implantation at the native tricuspid annulus level in humans.
In comparison to the evolving transcatheter aortic valve implantation, the TV anatomic features render transcatheter therapy more challenging. Obstacles for percutaneous repair approaches to the TV include the lack of stable adjacent structures for device placement, such as dilated annulus with its complex morphology of the TV; the dynamic geometry of the tricuspid annulus; and the absence of calcification. Furthermore, the close proximity of the coronary sinus ostium, atrioventricular node, and inferior vena cava to the TV result in many more technical difficulties for successfully deploying percutaneous repair devices. However, technology continues to advance, and newer techniques are being developed and tested in the preclinical setting to overcome these challenges before application in humans.
Bai et al. (24) described transcatheter implantation of a porcine pericardial valve in the tricuspid position in 10 healthy sheep under fluoroscopic guidance. Two deaths occurred periprocedurally related to cardiac arrhythmias. No significant TR developed in any animals during the follow-up period (24). Boudjemline et al. (25) have reported successful insertion of a novel percutaneous TV. Complications that were reported in this study include entrapment of the device in tricuspid chordae, leading to its incomplete valve opening, and a significant PVL in a separate animal. This device has not yet advanced to human studies (25). We developed a novel bioprosthesis that fulfilled all criteria required for successful transcatheter TV replacement without cardiopulmonary bypass using 2 different access approaches. Feasibility of the NaviGate prosthesis was tested in long-term preclinical models with overall satisfactory results. Echocardiography showed no significant post-implantation TR or high transvalvular gradients. There was no obstruction of RVOT, coronary arteries, or subvalvular apparatus. The valve anchoring was facilitated by a combination of 3 principles: a gentle radial force of the stent over the TA, a truncated cone or frustum configuration design that uses the RV pressure in systole to maintain the stented valve in proper position, and ventricular winglets that engage the tricuspid annulus, together creating a strong valvular seal.
Small atrial winglets covered with a lining of woven microfiber polyester fabric allow for a low intrusion of the valved stent into the RA; protect the integrity of anatomic structures, such as coronary sinus and conduction bundle; and also prevent PVL, minimizing dislocation toward the adjacent chambers. At this time, the NaviGate device has been implanted in 3 patients in the tricuspid position with no conduction disturbance complications (26).
Study limitations
An important limitation is the use of healthy animal models, because the TV is not enlarged with a very small atrial cavity that precludes substantial extension of the bioprosthesis and easy navigation inside the RA. The healthy pig differs widely from the patient presenting with moderate or severe tricuspid incompetence. Specifically, in humans with long-standing TR resulting from annular dilatation, the tricuspid annulus is >40 mm in diameter in many cases, which is very different from the model used in our study.
Achieving a good measurement of the TA as well as good visualization during valve deployment is critical to avoid mismatch of the TV prosthesis to the native TA; we experienced a total valve migration because of inappropriate TA measurements with intracardiac and transesophageal echocardiogram. That is why imaging technologies such as computerized tomography and 3-dimensional echocardiography are extremely important to provide more accurate guidance when performing transcatheter valve implantation in humans. However, using these imaging technologies would be challenging in our study, as they are not found in animal laboratories as a rule.
The valved stent could not be completely retrieved once released, so to avoid paravalvular leak in the presence of a larger tricuspid annulus, the size of the valved stent should be larger for pathological TR.
Tricuspid valve disease continues to present a challenging problem to cardiovascular specialists, especially in patients who develop tricuspid insufficiency associated with left heart valve disease or severe RV dysfunction. Because reoperation for recurrent TR carries high mortality rates and recurrence of TR after surgical repair is common, few patients are offered reoperation. Percutaneous approaches to TV disease could be an attractive alternative solution. In addition, the less invasive strategies may allow for earlier TR intervention than is currently practiced. There are many challenges and obstacles to emerging percutaneous approaches; however, with the advancement of cardiac imaging and percutaneous devices, development in this area is likely to continue.
This preclinical evaluation shows that transcatheter NaviGate TV orthotopic implantation in a chronic porcine model is feasible and safe and results in a secure and stable engagement of the native annulus with excellent hemodynamics and valve performance. This new device offers both percutaneous and minimally invasive implantation technique options without the need of cardiopulmonary bypass, which may be a potential effective alternative treatment for high-risk patients who are unsuitable for traditional cardiac surgery with severe TR and compromised RV function.
COMPETENCY IN MEDICAL KNOWLEDGE: Transcatheter valve therapy has been progressively evolving to provide alternative options for high-risk surgical patients. In this work, we have tested the feasibility of the NaviGate valved stent in an animal model in preparation for clinical application. Two delivery approaches are of particular value for high-risk patients with recurrent TR after prior cardiac surgery. Different sizes of the NaviGate valved stent are available to treat functional TR with dilated annulus and for implantation in a previously placed annuloplasty ring.
TRANSLATIONAL OUTLOOK: At this time, the NaviGate valved stent has been successfully implanted in 2 patients who are at prohibitive surgical risk with severe TR. The short-term results suggest that the procedure is safe and feasible. Further development of the current device and delivery system is ongoing to achieve optimal clinical results.
The Cleveland Clinic has an ownership position on patents licensed to the company; and holds stock in NaviGate Cardiac Structures, Inc. Dr. Navia is the inventor on patents related to this device; and has served as a consultant to and holds stock in NaviGate Cardiac Structures, Inc. Dr. Kapadia has served on the advisory board of Navigate; and has stock options in NaviGate Cardiac Structures, Inc. Dr. Quijano is an inventor on patents related to this device; and holds stock in NaviGate Cardiac Structures, Inc. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
All authors attest they are in compliance with human studies committees and animal welfare regulations of the authors' institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Basic to Translational Science author instructions page.
- Abbreviations and Acronyms
- intracardiac echocardiography
- paravalvular leak
- right atrium
- right heart failure
- right ventricle/ventricular
- right ventricle outflow
- tricuspid annulus
- tricuspid regurgitation
- tricuspid valve
- Received August 15, 2017.
- Accepted August 25, 2017.
- 2018 The Authors
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- Braunwald N.S.,
- Ross J. Jr..,
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- Desai R.,
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- Martin R.P.,
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Tue., Feb. 12, 2013
WA Lege Day 30: Name that bridge — for a price
OLYMPIA -- Driving from Spokane to Seattle might take a motorist west on the Avista Highway, across the Microsoft Bridge to the Starbucks Expressway under a bill the Legislature is considering to sell the rights to put corporate or other names on the state's roads, bridges, tunnels and ferries.
Some members of the Senate Transportation Committee made light of the idea, wondering for example, if every legislator would get a chance to name at least one structure after themselves and what it would cost to rename the Tacoma Narrows Bridge the Chuck E. Cheese Bridge.
The cost is unclear, said the committee's staff. There's no cost estimate or fiscal analysis of the proposal.
A 2009 study on selling the naming rights to name the state's ferries estimated it that proposal could raise about $10 million a year, Dan O'Neal of the Washington State Transportation Commission said. Not a lot of money, but "it may have some merit" O'Neal said.
It's an idea the state should at least consider, Sen. Don Benton, R-Vancouver, said, if it will bring some money into the state's road project coffers. After all, that $10 million going into the state transportation fund would be money that isn't coming out of the taxpayers' pockets, he said.


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