1995-06-27 Assigned to MEDTRONIC, INC. reassignment MEDTRONIC, INC. ASSIGNMENT OF ASSIGNORS INTEREST (SEE DOCUMENT FOR DETAILS). Assignors: HILL, MICHAEL R. S., MIN, XIAOYI, MONGEON, LUC R.
A method an apparatus for treating fibrillation, particularly atrial fibrillation. In response to detection of fibrillation, a high frequency, low energy pulse burst is delivered via pacing electrodes, accompanied by a high energy pulse delivered via defibrillation electrodes. The low energy pulse burst is preferably delivered to an area of the heart which exhibits relatively lower current density during delivery of the high energy pulse.
Reference is hereby made to commonly assigned, copending U.S. patent application Ser. No. 08/230,578, filed by Mongeon et al on Apr. 24, 1994 for a "Method and Apparatus for Treatment of Atrial Fibrillation", now abandoned.
The present invention generally relates to an implantable device for applying defibrillating electrical energy or shock to at least one chamber of a patient's heart in need of defibrillation, and to a method and apparatus for reducing the threshold energy required to effect the defibrillation and, in the case of atrial defibrillation, to thereby reduce the pain attendant to the delivery of the defibrillation energy.
Fibrillation has generally been treated by means of high energy cardioversion/defibrillation shocks or pulses, which, in the context of implantable anti-arrhythmia devices, are applied by means of large surface area electrodes, including an electrode on or in the chamber to be defibrillated. The high energy level is employed in order to simultaneously depolarize the bulk of the heart chamber to be defibrillated, which will include tissues in all stages of the depolarization-repolarization cycle at the time the pulse is delivered.
Over the years, numerous methods have been proposed for pacing or synchronously cardioverting a heart chamber in an attempt to interrupt tachycardias other than fibrillation. The pacing therapies include such pacing modalities as overdrive pacing, burst pacing, autodecremental overdrive pacing, and others, and synchronization with the underlying heart depolarizations may or may not be included. These pacing modalities have been formulated to interrupt aberrant reentrant conduction which may lead to sustained tachycardias in one or more chambers of the heart.
It has also been proposed that tachycardias could be prevented or interrupted by the use of simultaneous or timed multi-site cardiac pacing. One early example of multi-site cardiac pacing to terminate or prevent tachyarrhythmia is disclosed in U.S. Pat. No. 3,937,226 issued to Funke. In this device, a number of small surface area pacing electrodes are provided, each coupled to a separate output circuit and amplifier. The disclosed device is equivalent to five or more separate cardiac pacemaker output circuits of conventional design, all adapted to be triggered to pace simultaneously at various locations around the heart. It is hypothesized that by stimulating simultaneously at locations spread around the heart, synchronous with a sensed QRS complex, arrhythmias could be prevented by producing a more nearly simultaneous depolarization of cardiac tissues.
These approaches have been proposed and tested in the hope that the low energy pacing pulses would terminate the tachyarrythmia without having to resort to higher energy cardioversion therapies. This has been particularly of interest for treating frequently recurring tachyarrhythmias, since the battery life of the stimulation device depends on the amount of energy expended in delivering a therapy and the delivery frequency.
In the case of atrial fibrillation, the patient is not rendered unconscious if the ventricles continue to provide adequate cardiac output. Unfortunately, the quantity of electrical energy which is required to defibrillate the atria is sufficient, in most cases, to cause a sudden, propagated pain in the patient's chest area or to stun the patient. Typically reported defibrillation thresholds between transvenous leads bearing electrodes placed in the right atrium and/or superior vena cava (RA/SVC) and in the coronary sinus (CS) often exceed 2 J. Significant discomfort and or extreme pain can be associated with transvenous shock therapy in this range, resulting in sedation of some patients and refusal to accept the therapy by other patients.
Use of pacing energy pulses delivered at multiple sites within the atria to prevent the occurrence of atrial tachyarrhythmias including atrial flutter, which may in some cases progress to atrial fibrillation, has been investigated. For example, the article "Prevention of Atrial Tachyarrhythmias Related to Advanced Interatrial Block by Permanent Atrial Resynchronization", by Daubert et al, PACE, Vol.14, P. 648, 1991, discloses the use of synchronized pacing pulses delivered to the right and left atria to prevent onset of atrial tachyarrhythmias.
Recently, the theoretical possibility of employing low energy pacing level pulses (i.e. less than 0.05 joules) to treat atrial fibrillation has been explored. For example, in the recent article "Regional Control of Atrial Fibrillation by Rapid Pacing in Conscious Dogs", by Allessie et al, published in Circulation, Volume 84, No. 4, October 1991, pages 1689-1697, the ability of pacing pulses to capture a small area of fibrillating atrial tissue, if applied during a specified time interval synchronized to the sensed depolarization waveform at the pacing electrode site has been demonstrated. However, the depolarization wavefront created by such pulses does not propagate through the entire chamber, due to the varying polarization states of the tissue surrounding the stimulation site. In the above cited application by Mongeon et al, delivery of high frequency, unsynchronized low energy pulse bursts to one or more sites in the heart is proposed as a treatment for atrial fibrillation.
Delivery of pulse bursts to the atrium in the presence of atrial fibrillation is also disclosed in U.S. patent application Ser. No. 08/082,327, for a "Method and Apparatus for Treatment of Atrial Fibrillation and Flutter", filed Jun. 24, 1993 by Bardy et al. In this device, pulse bursts are delivered in response to detected high ventricular rate, in patients having persistent or frequent atrial fibrillation. The pulse bursts are synchronized to individual heart depolarizations and are intended to stimulate the nerves within the AV nodal fat pad, to produce partial heart block and thus reduce ventricular rate, if it is tracking the high atrial rate.
Delivery of high frequency pulse bursts to the atrium is also known to induce atrial fibrillation, unless synchronized to atrial depolarizations or P waves to assure that the pulse bursts occur within the refractory period of the atrium. This effect is discussed in U.S. patent application Ser. No. 08/086,278, for a "Method and Apparatus for Treatment of Angina", filed Jun. 30, 1993, by Bardy, which discloses a device which provides pulse bursts to the atrium, synchronized to detected atrial depolarizations, to stimulate the SA nodal fat pad and reduce the sinus rate of patients who suffer from angina.
Synchronization to a high atrial or ventricular depolarization rate may be difficult to accomplish. In commonly assigned U.S. Pat. No. 5,193,536 to Mehra, a pacemaker/cardioverter/defibrillator is described where the high atrial or ventricular rate is made more regular by delivering overdrive pacing pulses into a tachycardia, which are intended to individually capture or pace the entire heart chamber (not believed possible in the case of fibrillation) and by using the last overdrive pacing pulse delivered as a synchronization event to time the delivery of a cardioversion pulse. Another method of employing pacing pulses as an aid to synchronization of cardioversion pulses is disclosed in U.S. Pat. No. 5,074,301 to Gill where a single pacing pulse is delivered to the atrium to allow a ventricular cardioversion pulse to be delivered in the atrial refractory period.
In U.S. Pat. No. 5,318,591 issued to Causey et al., charging of the high voltage capacitors during antitachycardia pacing is disclosed, to allow prompt delivery of a cardioversion pulse in the event the antitachycardia pacing pulses are unsuccessful in terminating a detected tachycardia. In U.S. patent application Ser. No. 08/159,351, filed Nov. 29, 1993 by Olson for an "Apparatus and Method for Treating a Tachyarrhythmia", a similar device is disclosed. Both the Olson and Causey devices treat antitachycardia pacing and high voltage shock as separate therapies and thus require a period of time following termination of the antitachycardia pacing pulses to check whether the pacing pulses were effective in terminating the tachyarrhythmia, and precondition the delivery of the high voltage shock on failure to terminate.
In U.S. Pat. Nos. 5,314,448 and 5,366,485 to Kroll et al., a cardioverter/defibrillator is described having a set of defibrillation electrodes arranged around the patient's heart. When fibrillation is detected, the high output capacitors begin to be charged. As they are charged or after full charge is achieved, a "pretreatment" of the fibrillating heart muscle is commenced through the generation of a train of pulses from the voltage on the output capacitors and delivery of the pulses across the defibrillation electrodes. The capacitors are recharged and at the end of the recharge time period, the high energy defibrillation pulse is delivered across the defibrillation electrodes. It is stated that the pretreatment pulses begin the process of organizing the chaotically contracting myocardial cells and result in a reduction of cardioversion threshold and the total energy expended. It is emphasized that the pretreatment pulse voltages are well in excess of pacing level voltages and that the same cardioversion electrodes are employed to deliver the energy to the same myocardial cells as will be defibrillated by the cardioversion pulse.
Despite these advances, a need continues to exist for atrial and ventricular cardioversion systems that can defibrillator the atria or ventricles at low energy to decrease energy consumption and pain perceived by the patient.
It is therefore an object of the present invention to provide an atrial or ventricular defibrillation method and apparatus that operates to defibrillate the atria or ventricles with lower energy pulses than otherwise would be required.
The present invention is directed toward providing a method and apparatus for reducing the defibrillation threshold by using a combined therapy including a burst of pacing energy, high frequency pulses applied into a low current density region of the cardiac tissue in the chamber in fibrillation in conjunction with the delivery of defibrillation pulses. It is not intended that the pulse burst itself terminate the detected fibrillation, and no attempt is made to determine whether the pulse burst has affected the heart rhythm as a precondition to high energy shock delivery. The burst of pacing energy pulses is delivered to a pacing electrode or electrodes located within the heart chamber in fibrillation, in an area which exhibits a relatively lower current density during application of a defibrillation pulse. The burst of pacing energy pulses injected into the low current density region is believed to result in an area of refractory, depolarized tissue and/or an increased opportunity of depolarization wavefront collisions in the vicinity of the pacing electrode or electrode with the result that the defibrillation threshold for the following defibrillation pulse is lowered. The delivery of the pulse burst may also prevent ectopic beats originating in the low energy region from re-fibrillating the heart, after delivery of the defibrillation pulse.
While it is believed that the invention may be of benefit in reducing ventricular cardioversion energy thresholds, the invention is believed primarily valuable in the context of treating atrial fibrillation, as reducing the energy of the defibrillation shocks or pulses delivered to the atrium reduces both the associated level of pain and reduces the possibility that such shocks could trigger ventricular tachycardia or fibrillation.
The present invention surprisingly addresses these objectives by applying a pulse burst to the heart chamber of a type known to induce fibrillation, in conjunction with delivery of a defibrillation pulse. The pulse burst comprises a series of low energy pulses, typically less than about 10.0 volts, preferably of about 5.0 volts or less. The pulse frequency is preferably greater than 20 Hz, typically in the range of about 50-200 Hz. The burst is typically asynchronous to sensed heart depolarizations in the fibrillating heart chamber, and delivery may be commenced during the charge up of the high voltage, cardioversion energy, capacitors. The burst duration may be on the order of 1 to 5 seconds, with pulse bursts in the vicinity of 1 second preferred in the atrium. The burst may continue during the delivery of the defibrillation pulse and terminate just prior to the end of delivery of the defibrillation pulse. Alternatively, the burst may be terminated immediately prior to or a short interval prior to delivery of the defibrillation pulse to the defibrillation electrodes.
FIG. 3 is a waveform diagram of three defibrillation therapies in accordance with the present invention.
The timed delivery of pacing energy pulse bursts to pace/sense electrodes in the heart chamber to be defibrillated in relation to the subsequent delivery of a defibrillation shock or pulse to defibrillation electrodes for the same heart chamber may be implemented in a modified single chamber or dual pacemaker/cardioverter/defibrillator with any of the known pacing and defibrillation lead/electrode systems for single or dual chamber use. The invention may be practiced in a single chamber embodiment using separate pace/sense and defibrillation electrodes. However, the preferred use of the invention in lowering atrial defibrillation thresholds to reduce pain to the patient and to prolong battery life may be practiced in an embodiment using separate atrial pace/sense and defibrillation electrodes, along with a set of ventricular sense electrodes (and a ventricular sense amplifier and processing circuit) for detecting ventricular heart depolarizations so that the atrial defibrillation pulse is timed to fall outside the vulnerable period of the ventricle to lessen the risk of provoking ventricular fibrillation. In this case, due to the possibility of inducing ventricular fibrillation, the device may take the form of a pacemaker/cardioverter/defibrillator of the type depicted in FIG. 1, which also includes ventricular defibrillation capabilities, to provide an extra margin of safety. In such a comprehensive, dual chamber, pacemaker-cardioverter-defibrillator system embodiment of the invention, any of various embodiments of the invention may also be practiced by suitable programming of the specific operations performed by the system components.
FIGS. 1 and 2 therefore illustrate a comprehensive dual chamber system which is illustrative of all disclosed embodiments of the invention. FIG. 1 schematically illustrates such a pacemaker/cardioverter/defibrillator system 150, including a pulse generator 152 and a lead set, including a CS lead 130, an RA/SVC lead 140, and a ventricular or RV lead 160. The RV lead 160 may take the form of the ventricular leads disclosed in the above cited patents issued to Bardy, and includes three coaxial, coiled wire conductors separated from one another by tubular insulating sheaths. A ring electrode 164 and an extendable helix tip electrode 166, mounted retractable within an insulating electrode head 168, are located adjacent the distal end of the lead 160 and form a ventricular pace/sense, bipolar electrode pair. An elongated, exposed coil, defibrillation electrode 162 is located proximally to electrode head 168 and within the right ventricle. The RV defibrillation electrode 162 may be fabricated from platinum, platinum alloy or other materials known to be usable in implantable defibrillation electrodes and may be about 5 cm in length. Pace/sense electrodes 164 and 166 are employed for ventricular cardiac pacing and for sensing ventricular depolarizations or R-waves in a manner well known in the art. Each of the electrodes 162, 164, and 166 is coupled to one of the coiled conductors within the RV lead 160 which are coupled to three respective electrical connectors in a proximal end, bifurcated connector 158 which is in turn attached to receptacles in a connector block 154.
The RA/SVC lead 140 is constructed in a similar manner and includes a J-shaped distal end with a ring electrode 146 and an extendable helix electrode 148, mounted retractable within an insulating electrode head 144, forming an atrial pace/sense, bipolar electrode pair. Each of the electrodes 146 and 148 are coupled to one of the coiled conductors within the body of the RA/SVC lead 140 and are employed for atrial pacing and for sensing atrial depolarizations or P waves in a manner well known in the art. An elongated, exposed coil atrial defibrillation electrode 142 is also provided, proximal to electrode 146 and coupled to the third conductor within the body of RA/SVC lead 144. Electrode 142 preferably may be about 10.0 cm in length or greater and is configured to extend from the SVC into the RA and toward the tricuspid valve. A bifurcated connector 138 which carries three electrical connectors, each coupled to one of the coiled conductors, is formed at the proximal end of the RA/SVC lead 140 for connection into receptacles of connector block 154.
The CS lead 130 includes a single coiled wire conductor, coupled to an elongated, exposed coil defibrillation electrode 132. CS electrode 132, illustrated in broken outline, is located within the coronary sinus and great vein of the heart 10 and may be about 5.0 cm long. A connector 128 is coupled to the coiled conductor of the CS lead 130 and inserted into a further receptacle of the connector block 154.
The system 150 includes the pulse generator 152 in combination with the leads, with the lead connector assemblies 128, 138, 158 inserted into the connector block 154. The atrial and ventricular leads 130, 140, 160 and the associated pace/sense and cardioversion electrodes may take the form of those corresponding leads disclosed in commonly assigned U.S. Pat. Nos. 5,174,288 to Bardy or 5,165,403 to Mehra.
In addition, the system of electrodes may include a subcutaneous plate defibrillation electrode of the type described in the '288 patent to Bardy. Optionally, insulation of the outward facing portion of the housing of the pulse generator 152 may be provided using a plastic coating, for example parylene or silicone rubber, as is currently employed in some unipolar cardiac pacemakers. However, a portion of the housing may instead be left uninsulated and electrically connected to the defibrillation pulse generator to be used as a subcutaneous cardioversion/defibrillation electrode alone or in combination with one or more of the lead bearing cardioversion/defibrillation electrodes to cardiovert or defibrillate either the atria or ventricles.
It should be noted that the leads and electrode systems as described to this point in regard to FIG. 1 are comprehensive of atrial and ventricular electrode systems and cardioversion/defibrillation pathways that may be combined or separated depending on whether atrial or ventricular cardioversion/defibrillation therapy is undertaken in conjunction with the separate delivery of pacing pulse bursts in accordance with the present invention. As disclosed in U.S. patent application Ser. No. 08/293,769, filed by Min et al on Aug. 19, 1994 for an "Atrial Defibrillator and Method of Use", incorporated in its entirety herein, the addition of the ventricular lead 160 and defibrillation electrode 162 provides a further pathway for atrial defibrillation as well as a ventricular defibrillation pathway. In the former case, atrial cardioversion energy may be delivered between the RA/SVC electrode 142 (alone or optionally coupled with a subcutaneous electrode, e.g. pulse generator housing electrode 156 and the combination of the RV defibrillation electrode 162 and the CS electrode 132. In the latter case, particularly efficient ventricular cardioversion/defibrillation may be effected in a pathway between the RV electrode 162 and a distributed electrode formed by electrically connecting the CS electrode 132 in common with the RA/SVC electrode 23.
The relative current densities in the atria or ventricles during delivery of a defibrillation pulses are defined by the selection and positioning of the atrial defibrillation electrodes and by the three dimensional configurations and relative conductivities of the blood, heart tissue and adjacent body tissue. High current density regions are generally found at the sites of the defibrillation electrodes and low current density regions are generally more remote from the defibrillation electrode sites, with additional variability due to the tissue conductivities and configurations as discussed above. The current densities at various points in the atria can be mapped or simulated using finite element analysis. In the case of the lead system presently considered most practicable for use in treating atrial fibrillation, comprising electrodes located in the right atrium/superior vena cava and coronary sinus as discussed above, one of the lower current density areas is located in the region of the right atrial appendage. In the case of the lead systems presently considered most practicable for use in treating ventricular fibrillation, comprising electrodes located in the right ventricle and in the superior vena cava and/or subcutaneously, as discussed above, one of the lower current density areas is located in the region of the ventricular apex.
As such, the implant sites depicted in FIG. 1 for atrial pace/sense electrode pair 146, 148 and ventricular pace/sense electrode pair 164, 166 fall in low current density regions of the atria and ventricles, respectively, for some known transvenous/subcutaneous electrode combinations depicted, and thus are appropriately placed to practice the present invention.
In another aspect of the present invention, it is noted that following delivery of a defibrillation pulse, tissue in the areas of lower current density may recover from their refractory periods following delivery of a defibrillation pulse quicker than the bulk of the myocardial cells in the heart chamber subjected to the defibrillation pulse. Such an uneven recovery may contribute to unsynchronized depolarizations of cells in the low current density regions, possibly leading to re-fibrillation of the heart chamber. In practice, physicians program a higher defibrillation energy when re-fibrillation is seen or in anticipation of possible re-fibrillation, and the high energy fully saturates all myocardial cells of the heart chamber such that they recover at about the same time. The pulse burst of the present invention may assist in reducing the occurrence of re-fibrillation, without requiring as high a defibrillation pulse energy, due to prolongation of the refractory period of the tissue in the area adjacent the pacing electrodes.
Turning to FIG. 2, it is a functional schematic block diagram of an implantable atrial and/or ventricular pacemaker/cardioverter/defibrillator pulse generator in which the present invention may usefully be practiced. This diagram should be taken as exemplary of the type of pulse generator in which the invention may be embodied, and not as limiting, as it is believed that the invention may usefully be practiced in a wide variety of implementations, including atrial and ventricular only pacemaker/cardioverter/defibrillators which may or may not provide separate programmable anti-tachycardia and bradycardia pacing therapies, programmable cardioversion/defibrillation energies, staged therapies of both, or the like.
With this understanding in mind, the most comprehensive pacemaker/cardioverter/defibrillator pulse generator diagram of FIG. 2 will be described in conjunction with the lead/electrodes of the overall system 150 of FIG. 1. The pulse generator 150 is provided with a terminals schematically identified in FIG. 2 in the receptacles of connector block 154 for making electrical connection with the lead connectors 128, 138 and 158 and is also provided with the electrical terminal or catheter connector output 170 in connector block 154.
With respect to the terminals 310, 311, 318 and 320, terminal 310 is optionally coupled to the un-insulated housing electrode 156. Terminal 320 is attached to RV lead connector 158, and specifically makes connection with the RV defibrillation electrode 162. Terminal 311 is adapted to make electrical connection with RA/SVC cardioversion electrode 142 through lead connector 138 and RA/SVC lead 140. Terminal 318 is adapted to make electrical connection with CS cardioversion electrode 132 through lead connector 128 and CS lead 130.
Terminals 310, 311, 318 and 320 are coupled to high voltage output circuit 234 which includes high voltage switches controlled by cardioversion/defibrillation (CV/DEFIB) control logic 230 via control bus 238. The switches within circuit 234 control which cardioversion electrode sets are employed and which are coupled to the positive and negative terminals of the high voltage output capacitor bank including capacitors 246 and 248 during delivery of the cardioversion shocks.
With respect to the terminals 317, 321, 324 and 326, terminals 324 and 326 are adapted to make electrical connection through connector 158 of RA lead 160 with the ventricular pace/sense electrode pair 164, 166. Terminals 324 and 326 are coupled to the R-wave sense amplifier 200, which preferably takes the form of an automatic gain controlled amplifier providing an adjustable sensing threshold as a function of the measured R-wave amplitude. A V-SENSE signal is generated on R OUT line 202 whenever the signal sensed between electrodes 612 and 614 exceeds the present sensing threshold.
Terminals 317 and 321 are adapted to make electrical connection through connector 138 of RA/SVC lead 140 with the atrial pace/sense electrode pair 146, 148. Terminals 317 and 321 are coupled to the P-wave sense amplifier 204, which preferably also takes the form of an automatic gain controlled amplifier providing an adjustable sensing threshold as a function of the measured P-wave amplitude. An A-SENSE signal is generated on P OUT line 206 whenever the signal sensed between terminals 317 and 321 exceeds the present sensing threshold.
Switch matrix 208 is used to select which of the available terminals are coupled to wide band (0.5-200 Hz) amplifier 210 for use in digital signal analysis. Selection of electrodes is controlled by the microprocessor 224 via data/address bus 218, which selections may be varied as programmed-in through RF transmitter receiver 102 and stored in RAM 226. Signals from the electrodes selected for coupling to bandpass amplifier 210 are provided to multiplexer 220, and thereafter converted to multi-bit digital signals by A/D converter 222, for storage in RAM 226 under control of direct memory access circuit 228. Microprocessor 224 may employ digital signal analysis techniques to characterize the digitized signals stored in random access memory 226 to recognize and classify the patient's heart rhythm employing any of the numerous signal processing methodologies known to the art.
The pacer timing/control circuitry 212 includes programmable digital counters which optionally control the basic time intervals associated with DDD, WI, DVI, VDD, AAI, DDI and other modes of single and dual chamber pacing well known to the art. Circuitry 212 also controls escape intervals associated with anti-tachyarrhythmia pacing in both the atrium and the ventricle, employing any anti-tachyarrhythmia pacing therapies known to the art.
Intervals defined by pacing circuitry 212 include atrial and ventricular pacing escape intervals, the refractory periods during which sensed P-waves and R-waves are ineffective to restart timing of the escape intervals and the pulse widths of the pacing pulses. The durations of these intervals are determined by microprocessor 226, in response to stored data in RAM 226 and are communicated to the pacing circuitry 212 via address/data bus 218. Pacer circuitry 212 also determines the amplitude of the cardiac pacing pulses under control of microprocessor 224.
During pacing, the escape interval counters within pacer timing/control circuitry 212 are reset upon sensing of R-waves and P-waves as indicated by a signals on lines 202 and 206, and in accordance with the selected mode of pacing on timeout trigger generation of pacing pulses by pacer output circuitry 214 and 216, which are coupled to terminals 317, 321, 324 and 326. The escape interval counters are also reset on generation of pacing pulses, and thereby control the basic timing of cardiac pacing functions, including anti-tachyarrhythmia pacing. The durations of the intervals defined by the escape interval timers are determined by microprocessor 224, via data/address bus 218. The value of the count present in the escape interval counters when reset by sensed R-waves and P-waves may be used to measure the durations of R-R intervals, P-P intervals, P-R intervals and R-P intervals, which measurements are stored in memory 226 and used to detect the presence of tachyarrhythmias.
Microprocessor 224 operates as an interrupt driven device, and is responsive to interrupts from pacer timing/control circuitry 212 corresponding to the occurrence sensed P-waves and R-waves and corresponding to the generation of cardiac pacing pulses. These interrupts are provided via data/address bus 218. Any necessary mathematical calculations to be performed by microprocessor 224 and any updating of the values or intervals controlled by pacer timing/control circuitry 212 take place following such interrupts.
For example, in response to a sensed or paced ventricular depolarization or R-wave, the intervals separating that R-wave from the immediately preceding R-wave, paced or sensed (R-R interval) and the interval separating the paced or sensed R-wave from the preceding atrial depolarization, paced or sensed (P-R interval) may be stored. Similarly, in response to the occurrence of a sensed or paced atrial depolarization (P-wave), the intervals separating the sensed P-wave from the immediately preceding paced of sensed atrial contraction (P-P Interval) and the interval separating the sensed P-wave from the immediately preceding sensed or paced ventricular depolarization (R-P interval) may be stored. Preferably, a portion of the RAM 226 is configured as a plurality of recirculating buffers, capable of holding a preceding series of measured intervals, which may be analyzed in response to the occurrence of a pace or sense interrupt to determine whether the patient's heart is presently exhibiting atrial or ventricular tachyarrhythmia.
Detection of atrial or ventricular tachyarrhythmias, as employed in the present invention, may correspond to tachyarrhythmia detection algorithms known to the art. For example, presence of atrial or ventricular tachyarrhythmia may be confirmed by means of detection of a sustained series of short R-R or P-P intervals of an average rate indicative of tachyarrhythmia or an unbroken series of short R-R or P-P intervals. The suddenness of onset of the detected high rates, the stability of the high rates, or a number of other factors known to the art may also be measured at this time. Appropriate ventricular tachyarrhythmia detection methodologies measuring such factors are described in U.S. Pat. No. 4,726,380, issued to Vollmann, U.S. Pat. No. 4,880,005, issued to Pless et al. and U.S. Pat. No. 4,830,006, issued to Haluska et al., all incorporated herein by reference in their entireties. An additional set of tachycardia recognition methodologies is disclosed in the article "Onset and Stability for Ventricular Tachyarrhythmia Detection in an Implantable Pacer-Cardioverter-Defibrillator" by Olson et al., published in Computers in Cardiology, Oct. 7-10, 1986, IEEE Computer Society Press, pages 167-170, also incorporated herein in its entirety. However, one of the advantages of the present invention is that it is believed practicable in conjunction with most prior art tachycardia detection algorithms.
In the event that an atrial or ventricular tachyarrhythmia is detected, and an anti-tachyarrhythmia pacing regimen is desired, appropriate timing intervals for controlling generation of anti-tachyarrhythmia pacing therapies are loaded from microprocessor 224 into the pacer timing and control circuitry 212. Burst or overdrive pacing therapies are delivered through operation of the escape interval counters therein which also define refractory periods during which detection of R-waves and P-waves is ineffective to restart the escape interval counters.
In the event that generation of a cardioversion or defibrillation shock is required, microprocessor 224 employs the escape interval counter to control timing of such cardioversion and defibrillation pulses, as well as associated refractory periods of the sense amplifiers 200, 204. In response to the detection of atrial or ventricular fibrillation or tachyarrhythmia requiring a cardioversion pulse, microprocessor 224 activates CV/DEFIB control logic 230, which initiates charging of the high voltage capacitors 246 and 248 via charging circuit 236, under control of high voltage charging control lines 240 and 242. The voltage on the high voltage capacitors is monitored via VCAP line 244, which is passed through multiplexer 220 to the bus 218 and microprocessor 224. When the capacitor voltage reaches a predetermined value set by microprocessor 224, capacitor charging is terminated. Thereafter, timing of the delivery of the cardioversion/defibrillation pulse is controlled by pacer timing/control circuitry 212.
In the context of treating atrial fibrillation, it is desirable to synchronize the delivery of the atrial cardioversion pulse with an R-wave sensed by R-wave sense amplifier 200 in a manner as disclosed in PCT Application No. US92/02829, Publication No. WO 92/18198 by Adams et al, incorporated herein by reference in its entirety. In this reference, careful synchronization of the high voltage atrial defibrillation pulse to the ventricles to avoid inducing of ventricular tachycardia or fibrillation is discussed. Delivery of an atrial defibrillation pulse at an inappropriate time may induce ventricular arrhythmias, including ventricular fibrillation.
In the illustrated comprehensive pulse generator, delivery of the atrial and/or ventricular cardioversion or defibrillation pulses is accomplished by output circuit 234, under control of CV/DEFIB control logic 230 via control bus 238. Output circuit 234 determines whether a monophasic or biphasic pulse is delivered, the polarity of the electrodes, and which electrodes are involved in delivery of the cardioversion pulse. Output circuit 234 also includes high voltage switches which control whether certain of the cardioversion electrodes are coupled together during delivery of the pulse. Alternatively, cardioversion electrodes intended to be coupled together during the pulse may simply be permanently coupled to one another, either exterior to or interior of the pulse generator device housing, and polarity may similarly be pre-set, as in current implantable pacemaker/cardioverter/defibrillator pulse generators. An example of output circuitry for delivery of biphasic pulse regimens to multiple electrode systems may be found in U.S. Pat. Nos. 4,727,877 and 4,953,551 incorporated by reference in their entireties. A specific switching circuit and explanation of the possible electrode combinations and benefits of such combinations is set forth in the above-referenced Minet al application.
Following delivery of the fibrillation or tachycardia therapy the microprocessor 224 then returns the pulse generator operating mode to cardiac pacing and awaits the next successive interrupt due to pacing or the occurrence of a sensed atrial or ventricular depolarization.
For purposes of implementing the present invention, FIGS. 1 and 2 illustrate comprehensively the pulse generator and lead/electrode components that may be selectively employed in one variation to provide atrial cardioversion alone or with ventricular cardioversion back-up if the atrial cardioversion energy induces ventricular fibrillation. In addition, the implementation of the present invention in a variation to provide ventricular only cardioversion/defibrillation therapies is also possible through selective use of the components of the system 150 of FIGS. 1 and 2.
Returning to the cardioversion/defibrillation therapy of the present invention, the pacer timing/control circuitry 212 includes programmable digital counters which optionally control the timing, generation, and delivery of the burst of pacing energy pulses in addition controlling the timing of the delivery of a defibrillation pulse as illustrated in FIG. 3.
The burst pulses may be generated in the same manner as in commercially available implantable neurostimulators, such as employed in the Medtronic® Itrel II nerve stimulator (delivering biphasic pulses). Alternatively, monophasic burst pacing pulse generation circuitry as provided by the Medtronic® Model 2349 Programmable stimulator may be employed. In testing the invention, the inventors employed a Model DTU215 Bloom® stimulator, and a Medtronic® Model 1349 stimulator, both of which produced monophasic pacing pulse bursts, as well as employing a WPI® brand nerve stimulator, which generated biphasic pulse bursts. For purposes of the present invention, any circuit capable of generating pacing energy pulse bursts should be sufficient, but it is believed that monophasic pacing energy pulses of the type illustrated in FIG. 3 are preferably employed. For example, the individual pulses may have a pulse width of about 0.5 ms-1.0 ms and a pulse amplitude of about 5.0 volts, recurring at 20.0 ms or a frequency of 50 Hz.
In the event that atrial or ventricular fibrillation is identified, the typical therapy will be delivery of a high amplitude defibrillation pulse, which may be in excess of 10.0 joules in the case of ventricular fibrillation and may be about 0.50 joule or greater, typically 2 joules or greater, in the case of atrial defibrillation. Lower energy levels will be employed for synchronized cardioversion to convert a high rate tachycardia. As in the case of currently available implantable pacemaker/cardioverter/defibrillator pulse generators, and as discussed in the above-cited references, it is envisioned that the amplitude of the defibrillation pulse may be incremented in response to failure of an initial pulse or pulses to terminate fibrillation.
It is possible that the combined burst pulse/high voltage therapy provided by the present invention will be successful to terminate all atrial fibrillation episodes in any single patient. Unlike ventricular fibrillation, atrial fibrillation is not an immediately life threatening condition. Repeated termination attempts can be undertaken without severe consequences. If the first burst and cardioversion pulse cycle is unsuccessful, multiple cycles may be repeated, with pulse frequency, pulse amplitude, burst duration, burst interval, and/or high energy pulse parameters varied between successive attempts. The pulse frequency may also be varied within a given burst. In particular, pulse burst parameters may be altered by incrementing the pulse frequency within each burst and increasing the duration of each burst. If a sequence of several burst cycles is unsuccessful, the device may disable the burst function for a period of time, e.g. a few hours or more, and renew attempts to terminate fibrillation thereafter. FIG. 3 illustrates the basic timing intervals associated with the delivery of a single pacing energy burst in relation to the delivery of a biphasic cardioversion/defibrillation pulse in first, second and third cardioversion therapies 400, 500, 600 that differ from one another as follows. If the first therapy 400 is directed to treatment of atrial fibrillation, the delivered burst 402 may extend over a programmed burst interval T1 that commences during or before the initiation of charging of the output capacitors 246, 248 at a time t1, chosen such that high voltage capacitor charging should be completed during the burst interval T1, with the burst terminating at time t2. The biphasic defibrillation pulse 404 is delivered at time t3, synchronized to a detected ventricular depolarization, resulting in a variable delay interval T2, determined by the time required to synchronize the delivery of pulse 404.
If the first therapy 400 is directed to treatment of ventricular fibrillation, the delivered burst 402 extends over a programmed burst interval T1 that commences during the charging of the output capacitors 246, 248 at a time t1, chosen such that capacitor charging should be completed during the burst interval T1, with the burst terminating at time t2 as discussed above, Alternatively, the burst interval T1 may be variable commencing at a time t1 chosen such that the expected time to completion of charging is equal to a desired burst interval, with termination of the burst occurring at the time the capacitors are fully charged at time t2. The biphasic defibrillation pulse 404 in either case may be delivered at time t3, following the end of burst interval T1 by a programmed delay interval T2.
The second therapy 500 differs from the first therapy 400 by eliminating the delay interval T2. If the second therapy 500 is directed to treatment of atrial fibrillation, the delivered burst 502 may extend over a variable burst interval T1 that commences during or before the charging of the output capacitors 246, 248 at a time t1, chosen such that capacitor charging should be completed at a time thereafter equal to or somewhat less than the desired burst interval, with the burst actually terminating at time t2, coinciding with delivery of defibrillation pulse 504 following completion of capacitor charging, synchronized to a detected ventricular depolarization.
If the second therapy 500 is directed to treatment of ventricular fibrillation, the delivered burst 502 extends over a programmed burst interval T1 that commences during the charging of the output capacitors 246, 248 at a time t1, chosen such that capacitor charging should be completed during the burst interval T1, with the burst terminating at time t2 as discussed above, Alternatively, the burst interval T1 may be variable commencing at a time t1 chosen such that the expected time to completion of charging is equal to a desired burst interval, with termination of the burst occurring at the time to capacitors are fully charged at time t2. The biphasic defibrillation pulse 504 in either case may be delivered at time t2, coincident with termination of the pulse burst 502.
The third therapy 600 differs from the first therapy 400 by eliminating the delay interval T2 and overlapping the burst interval T1 with the pulse width or duration T3 of the cardioversion pulse 604. If the third therapy 500 is directed to treatment of atrial fibrillation, the delivered burst 602 extends over a variable burst interval T1 that commences during or before the charging of the output capacitors 246, 248 at a time t1, chosen such that capacitor charging should be completed at a time thereafter equal to or somewhat less than the desired burst interval, with the burst actually terminating at time t2, during delivery of defibrillation pulse 604, at a predetermined interval following initiation of defibrillation pulse 604. Pulse 604 is synchronized to a detected ventricular depolarization following completion of capacitor charging.
If the third therapy 600 is directed to treatment of ventricular fibrillation, the delivered burst 602 extends over a programmed burst interval T1 that commences during the charging of the output capacitors 246, 248 at a time t1, chosen such that capacitor charging should be completed during the burst interval T1, with the burst terminating at time t2 as discussed above. Alternatively, the burst interval T1 may be variable commencing at a time t1 chosen such that the expected time to completion of charging is equal to a desired burst interval, with termination of the burst occurring at the time to capacitors are fully charged at time t2. The biphasic defibrillation pulse 604 in either case may be delivered at time t3, a predetermined interval prior to t2.
The three therapies are illustrative of different relationships of the pacing energy burst delivered to the pace/sense electrodes and into the low current density region and the associated high energy pulse delivered to the defibrillation electrodes. Following delivery of the combined therapy, the microprocessor 224 .analyzes the electrogram of the heart chamber undergoing the cardioversion therapy to determine whether fibrillation has terminated. If so, any succeeding programmed therapy is canceled. If fibrillation persists, the next scheduled therapy is delivered. Delivery of programmed therapies continues until exhausted. In the context of treatment of atrial fibrillation, if the programmed number of therapies is delivered without termination, therapy is preferably disabled for a period of time, e.g. one hour or more, to prevent excessive battery drain.
Variations and modifications to the present invention may be possible given the above disclosure. Although the present invention is described in conjunction with a microprocessor-based architecture, it will be understood that it could be implemented in other technology such as digital logic-based, custom integrated circuit (IC) architecture, if desired.
defibrillation pulse generator means responsive to said triggering means for generating said high energy pulses for delivering a high energy pulse to said defibrillation electrode means in conjunction with each delivery of a said pulse burst to said pacing electrode means.
means for initiating delivery of said high energy pulses during delivery of said pulse bursts.
means for initiating delivery of said high energy pulses on termination of said pulse bursts.
means for initiating delivery of said high energy pulses after a delay following termination of said pulse bursts.
5. A device according to claim 2 or claim 3 or claim 4 further comprising means for sensing depolarizations of a second chamber of said heart and wherein said control means comprises means for delivering said high energy pulses synchronized to detected depolarizations of said second chamber of said heart.
6. A device according to claim 2 or claim 3 or claim 4 wherein said pacing pulse generator means comprises means for delivering pacing energy pulse bursts having a frequency of about 50-200 Hz to said pacing electrode means.
delivering pacing energy pulse bursts having a frequency of 20 Hz or greater to said pacing electrode and delivering a high energy pulse to said defibrillation electrodes in conjunction with each delivery of said pulse bursts to said pacing electrode.
8. The method of claim 7, wherein said step of delivering said high energy pulses comprises initiating delivery of said high energy pulses during delivery of said pulse bursts.
9. The method of claim 7, wherein said step of delivering said high energy pulses comprises initiating delivery of said high energy pulses on terminations of said pulse bursts.
10. The method of claim 7, wherein said step of delivering said high energy pulses comprises initiating delivery of said high energy pulses after a delay following terminations of said pulse bursts.
11. A method according to claim 8 or claim 9 or claim 10 further comprising sensing depolarizations of a second chamber of said heart and wherein step of delivering said high energy pulses comprises delivering said high energy pulses synchronized to detected depolarizations of said second chamber of said heart. first chamber which is exhibits a relatively lower current density than other portions of said first chamber, during delivery of said high energy pulses.
12. A method according to claim 8 or claim 9 or claim 10 wherein said step of locating said pacing electrode comprises locating said pacing electrode in a region of said first chamber which exhibits a relatively lower current density than other portions of said first chamber, during delivery of said high energy pulses.
13. A method according to claim 8 or claim 9 or claim 10 wherein said step of delivering said pulse bursts comprises delivering pulse bursts having a frequency of 50-200 Hz.
wherein said step of locating said pacing electrode comprises locating said pacing electrode in a region of said first chamber which exhibits a relatively lower current density than other portions of said first chamber, during delivery of said high energy pulses.
delivering pacing energy pulse bursts to said pacing electrode and delivering a high energy pulse to said defibrillation electrodes, synchronized to detected depolarizations of said second chamber of said heart in conjunction with delivery of said pulse bursts to said pacing electrode.
16. The method of claim 14 or claim 15, wherein said step of delivering said high energy pulses comprises initiating delivery of said high energy pulses during delivery of said pulse bursts.
17. The method of claim 14 or claim 15, wherein said step of delivering said high energy pulses comprises initiating delivery of said high energy pulses on terminations of said pulse bursts.
18. The method of claim 14 or claim 15, wherein said step of delivering said high energy pulses comprises initiating delivery of said high energy pulses after a delay following terminations of said pulse bursts.
delivering pacing energy pulse bursts to said pacing electrode and delivering high energy pulses to said defibrillation electrodes during delivery of said pulse bursts to said pacing electrode.
defibrillation pulse generator means responsive to said triggering means for generating said high energy pulses for delivering a high energy pulse to said defibrillation electrode means in conjunction with delivery of a said pulse burst to said pacing electrode means, synchronized to a detected depolarization of said second chamber of said heart.
defibrillation pulse generator means responsive to said triggering means for generating said high energy pulses for delivering high energy pulses to said defibrillation electrode means during delivery of said pulse bursts to said pacing electrode means.
means for triggering delivery of a combined defibrillation therapy in response to detection of fibrillation in said first chamber of said heart; comprising means for triggering said pacing pulse generator means to deliver a pulse burst to said chamber of said heart and means for triggering said defibrillation pulse generator means to deliver a high energy pulse to said chamber of said heart in conjunction with delivery of said pulse burst to said chamber of said heart.
means for triggering delivery of a combined defibrillation therapy in response to detection of fibrillation in said first chamber of said heart; comprising means for initiating charging of said high voltage output capacitor, means for defining a first time interval which will expire after charging of said high voltage capacitor, means for triggering said pacing pulse generator means to deliver pulse bursts to said chamber of said heart commencing on the beginning of said first time interval and continuing until said high voltage capacitor is charged and means for triggering said defibrillation pulse generator means to deliver high energy pulses to said chamber of said heart means in response to said high voltage capacitor being charged.
27. A device according to claim 26 wherein said means for triggering said pacing pulse generator comprises means for terminating delivery of said pulse bursts on expirations of said first time intervals.
28. A device according to claim 26 wherein said means for triggering said pacing pulse generator comprises means for terminating delivery of said pulse bursts on deliveries of said high energy pulses.
wherein said means for triggering said defibrillation pulse generator means comprises means for triggering said defibrillation pulse generator means to deliver high energy pulses to said chamber of said heart means in response to a sensed depolarization of said second chamber of said heart, after said high voltage capacitor is charged.
delivering a combined defibrillation therapy, in response to detection of fibrillation in said first chamber of said heart, by employing said pacing pulse generator to deliver pulse bursts to said first chamber of said heart and by employing a defibrillation pulse generator means to deliver high energy pulses to said first chamber of said heart means in conjunction with delivery of said pulse bursts to said first chamber of said heart.
delivering a combined defibrillation therapy in response to detection of fibrillation in said first chamber of said heart by initiating charging of a high voltage output capacitor and defining a first time interval which will expire after charging of said high voltage capacitor, and delivering a low energy pulse burst to said first chamber of said heart commencing on the beginning of said first time interval and continuing until said high voltage capacitor is charged and discharging said high voltage capacitor to deliver a high energy pulse to said first chamber of said heart means in response to said high voltage capacitor being charged.
32. A method according to claim 31 wherein said pulse burst delivery step comprises terminating delivery of said pulse burst on expiration of said first time interval.
33. A method according to claim 32 wherein said pulse burst delivery step comprises terminating delivery of said pulse burst prior to delivery of said high energy pulse.
wherein said high energy pulse delivery step comprises delivering said high energy pulse in response to a sensed depolarization of said second chamber of said heart, after said high voltage capacitor is charged.
EP0420563B1 (en) 1996-12-27 Defibrillator delivering bursts dependent on the fibrillation cycle length.


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Once you have your button text you can change the font and font size, you can even add a drop shadow with layer styles if you wish. Now we want to have the button shape & button text aligned centrally. how to buy excess inventory from department stores 1/10/2015 · Mac IMac5. 16gb Ram. OS 10.9.5. Hello Gentleman I recently installed Photoshop CC 2015 the trial version , when I use the Blending option to add "Drop a shadow it don't show any shadow at all , when I increase or decrease the parameters , it don't have any effect on the actual picture...Help Please..
In Photoshop CC 2017 Essential Training: Design, Julieanne Kost created a course specifically for designers, with the goal of removing technical barriers so you can master the technology, start how to add alkalinity increaser to pool Once you have your button text you can change the font and font size, you can even add a drop shadow with layer styles if you wish. Now we want to have the button shape & button text aligned centrally.
Once you have your button text you can change the font and font size, you can even add a drop shadow with layer styles if you wish. Now we want to have the button shape & button text aligned centrally.
1/10/2015 · Mac IMac5. 16gb Ram. OS 10.9.5. Hello Gentleman I recently installed Photoshop CC 2015 the trial version , when I use the Blending option to add "Drop a shadow it don't show any shadow at all , when I increase or decrease the parameters , it don't have any effect on the actual picture...Help Please..


The Tbilisi Transport Company provided xml files of Tbilisi's bus routes. We are now sharing the JSON version. Still left to do: verify what the last bus routes are (routes > 150); convert the projection to a more common web projection to make it easier to use.


The ability to communicate effectively with others is an essential attribute of all highly successful people. It's about sharing, understanding and helping others to understand us. Managers who demonstrate sound communication skills are better placed to influence the behaviours of their team members and achieve organisation objectives.
This program focuses on the fundamental principles of communication and can be underpinned by Neuro-linguistic programming and/or Whole brain techniques. This ensures high level interest and the engagement of participants, as well as high levels of retention of information after the course is completed.


Your Knoxville, TN neighbors who have called on Innovative Roofing & Siding, Inc have plenty to say about their great experience with us. No other roofing contractors Knoxville, TN can match our combination of personal service and quality materials. Read for yourself what your neighbors are saying about Innovative Roofing & Siding, Inc.


Along the Texas Coast are barrier islands running parallel to the mainland. The longest barrier island is Mustang Island, where Port Aransas occupies 8 miles of its 18 mile length. We spent a month there with Gulf Waters RV Resort as our home base, then three days just up the road at Mustang Island State Park.
"Port A" as it's known by the locals, is a small beach community of about 3,500 people. Although the "Winter Texans" swell the population significantly each year, the town remains uncrowded and less frenetic than many we saw in Florida last year.
The big draw at Port Aransas is of course the beautiful Gulf beaches, with easy access to great offshore bay fishing. Thankfully, birding is right up there in popularity as well, so you know what I was doing during the few nice days we had during there!
Folks came out to enjoy a sunny day and fish at the South Jetty. Did I mention that fishing is popular here?
Vehicles and buggies are allowed to drive right on the beach here, so we just had to rent a buggy to join the fun and take a ride into town for lunch.
Now that's what you call camping on the beach!
In between our medical appointments in Corpus Christi, we visited the USS Lexington, an aircraft carrier which is now a museum on the Bay. You can probably guess who really enjoyed all of the "self- guided tours" on this giant ship – like a kid in a candy store!
For a more personalized experience aboard "Lady LEX", check Ingrid's post – A Trip down memory lane. Her husband Al, a navy pilot, earned his wings flying on and off the Lady LEX, so their visit was quite sentimental.
Our month-long stay at the beautiful, well-managed Gulf Waters RV Resort partially made up for the constant gloomy cold and windy days. More so as our site overlooked the pond where many birdies became our free entertainment, giving me lots of photo opportunities from inside our warm coach.
The goofy couple bidding goodbye to the Texas Coast. No more salt water for us for a while!
1) You don't like dealing with unpredictable weather.
2) You hate it when your GPS signal sometimes gets lost because you're so far north.
3) You don't like people who work at a more leisurely pace than you're used to.
4) You get aggravated when a Bear or Moose walk near the road you're driving on.
5) You don't like being in areas away from supermarkets or an internet connection.
6) You can't stand to drive a dirty car.
7) You don't like to fish, hunt or spend a lot of time outdoors.
8) You hate it when other drivers wave Hello at you all the time.
9) You think up to 20 hours of sunlight per day during the summer is a bad thing.
10) You get tired of eating the Best salmon and halibut in the world all the time.
But, if like us you think these are just some of the "minor inconveniences" that make Alaska an interesting and charming place, YOU MUST TRAVEL TO ALASKA for one of the best experiences of your life!


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President Obama Gives Final State of the Union Address
Jan 13, 2016Hot News, State/National NewsComments Off on President Obama Gives Final State of the Union Address
President Barack Obama gave his final State of the Union address Jan. 12, which White House officials said would be less traditional than past speeches, and the president touched on four major issues, including economic recovery, global climate change, keeping the country safe from terrorist threats, and fixing the country's broken political system.
President Obama touted the creation of over 14 million new jobs and 900,000 manufacturing jobs as successes during his presidency, and also said he's cut the country's deficits by over 75 percent.
"We're in the middle of the longest streak of private sector job creation in history," Obama stated. "More than 14 million new jobs, the strongest two years of job growth since the '90s, an unemployment rate cut in half. Our auto industry just had its best year ever. That's just part of a manufacturing surge that's created nearly 900,000 new jobs in the past six years. And we've done all this, while cutting our deficits by almost three-quarters."
The president also mentioned the nation's potential to become a leader in the area of climate change, and to capitalize on the opportunity to create clean energy sources, whether or not Republicans believe the problem actually exists.
"Look, if anybody still wants to dispute the science around climate change, have at it," Obama stated. "You will be pretty lonely, because you'll be debating our military, most of America's business leaders, the majority of the American people, almost the entire scientific community, and 200 nations around the world who agree it's a problem, and intend to solve it. But even if – even if the planet wasn't at stake; even if 2014 wasn't the warmest year on record, until 2015 turned out to be even hotter, why would we want to pass up the chance for American businesses to produce, and sell, the energy of the future?"
He also spoke about confronting threats from the terrorist group ISIL, and refuted the calls from some Republicans, likely pointing a finger at Donald Trump, that we should classify all Muslims as being a threat from the Islamic state.
"His Holiness, Pope Francis, told this body, from the very spot that I'm standing on tonight, that 'to imitate the hatred and violence of tyrants and murderers is the best way to take their place,'" the president stated. "When politicians insult Muslims, whether abroad or our fellow citizens; when a mosque is vandalized, or a kid is called names, that doesn't make us safer. That's not telling it like it is. It's just wrong. It diminishes us in the eyes of the world. It makes it harder to achieve our goals. It betrays who we are as a country."
Yet, despite the successes of his administration he mentioned during his address, Obama said his only regret was that he hadn't achieved more bi-partisanship.
"It's one of the few regrets of my presidency, that the rancor and suspicion between the parties has gotten worse instead of better," he stated. "I have no doubt a president with the gifts of Lincoln or Roosevelt might have better bridged the divide, and I guarantee I'll keep trying to be better so long as I hold this office."
Obama said he also pledged to create an effort to cure cancer, which he said would be spearheaded by Vice President Joe Biden.
Biden's son, Beau Biden, passed away from the disease last year.
"Last year, Vice President Biden said that, with a new moonshot, America can cure cancer," the president stated. "Last month, he worked with this Congress to give scientists at the National Institutes of Health the strongest resources that they've had in over a decade. So tonight, I'm announcing a new national effort to get it done. I'm putting Joe in charge of mission control."
Obama also highlighted his nuclear deal with Iran, and the country's renewed relationship with Cuba as additional successes of his administration.
The State of the Union will likely be one of the president's final, major speeches, aside from an address later this year at the Democratic National Convention.
Gov. Nikki Haley of South Carolina gave the Republicans' rebuttal to the speech, and cited an agenda in contrast to the president's plans.
"As he enters his final year in office, many Americans are still feeling the squeeze of an economy too weak to raise income levels," Haley stated. "Even worse, we are facing the most dangerous terrorist threat our nation has seen since Sept. 11, and this president appears either unwilling, or unable, to deal with it."
"If we held the White House, taxes would be lower, spending slowed, and the military strengthened," she said.
View the president's full address at https://www.whitehouse.gov/sotu.
View the Republicans' response at http://sotu.gop.gov//.
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biznizz replied to Spin Attaxx's topic in Green Grove Zone
Honestly, I think that the continuation of All-Star Batman & Robin (or Dark Knight, Boy Wonder if you wanna call it that) would be released before the first GN of Lara-Su. Either that or Dark Knight 4. You know it's sad when Frank Miller has a better chance of doing either because Brian Azzarello basically asked Miller what the plot for a potential sequel would be, then basically wrote it himself. Ain't anyone doing that for ol' Pen.
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Archie Sonic Main Discussion
biznizz replied to Toby's topic in Green Grove Zone
...But will she still going to be a living lie detector that will prevent anyone from lying in front of her that will be mentioned only once and never again?
I think that picture of Xero is at least 2 years old; it certainly isn't new. It's hard to even see him and Lara as even the same species. Maybe in the same familial taxonomy, but definitely not in species.
I'm back after another hiatus, and, honestly, I'm surprised that Ken actually did something by releasing Geoffrey's bio. And it is as bad as I expected. Ugh. This just makes me think that, in addition to wanting reprint rights and the cash that'd come with it, the real reason Pen wants to buy out the old creators' copyrights is because, literally, he was too lazy to try to rewrite history without them. And would someone, for the love of all that's good, please tell me if they're still supposed to be aliens or not, if Ech'chyd,nya is actually still a thing or what.
Well, we got Naugus and Wendy, plus Breezie is pretty much severed ties with Eggman. As did Snively for the time being. Nack & his team are work for hire; Eggman just hires them a lot. My guess is that the BBA were basically strong armed into joining the Eggman Empire, like the Dark Legion in the old continuity. I hope that they only joined to avoid Eggman's wrath, not because they are actually loyal to his cause.
Super Mario Bros. Z
biznizz replied to Kuzu's topic in Chit-Chat
He'd been having regrets about the series since before he decided to stop it ages ago, I know that for sure. He didn't like that Mecha Sonic was just the one from S3&K (and it was probably a b*tch to manipulate with how limited it is), and IIRC, he had immediate regrets about Basilisk. What I'm curious about is if all of Sonic's friends are still dead-dead.
I'm not really buying that "My wife didn't tell me" excuse. Ken's always been chomping at the bit to spread his name around so, even if he doesn't really prioritize video games at all (sticking to TV & film). So you'd think that if a large, well-known video game company asked him to do some consulting work or an upcoming SONIC game, she would tell him. My guess is that it's a half truth. He probably was busy with something, Bioware left a message with his wife, and then when she told him, Ken decided that it wasn't important enough to actually give a sh*t about.
So wait, is The Storm going to be included in the physical copy of the first book or is it strictly digital only? I mean, from the descriptions of it, it's largely pointless as it follows Remington and Geoffrey, two characters who I believe aren't even going to BE in LSC proper, but some equality for physical and digital releases is the least he could do.
Okay, dude... No one's gonna rip you a new one everytime you express an opinion. You've certainly had some... divisive ones, but something like that isn't going to cause any drama. But yeah, Hope ain't coming back at all. First because she's a Karl Bollers character and Archie pretty much dumped previous pre-Flynn OC's even if they weren't made by Penders. Second, her character would already have to be severely altered to fit that (there aren't Kintobor's anymore just Robotniks, she'd have to be made evil, and she'd probably be related to Snively but certainly not Eggman due to mandates). But you did get me thinking with the AoStH thing. With Schlemmer and Breezie, it actually wouldn't be much of a stretch for it to be someone like Warpnik, or even Caninestein (though he was a good guy on the show, so he'd make a heel turn if this was the case...) That certainly would be a surprise to me, especially in an arc with Wendy 'Witchcart' Naugus and her three Witchcarters as baddies.
I wouldn't say it's Snively as the 12th Egg Boss; they showed he was still evil in the Dark Arms on Angel Island arc, and his Origins showed that while still secretly evil, he doesn't have any current relationship with Eggman at the moment. The fact that it's a "reveal" in the final issue of the arc implies that it'd be someone that we wouldn't expect, or has enough power or clout that it'd be shocking to find out who they were. The only ones who'd be shocking enough that I can think of off the top of my head are all improbable to the point of being impossible: Fiona Fox, Eggman Nega, Chris Thorndyke, or Tiara. The former being stuck in a legal limbo that I don't know who owns her character, the latter three having one hang-up or another due to SEGA mandates.
Family drama was kinda a thing for a long while in the book. To be fair, it wasn't just Penders who did it; Bollers and Flynn are equally guilty of that too. Locke's whole deal was talked about a lot prior in the topic, so I'd go through that if you are curious and have time to kill. I think most of it survived the site having a stroke from a while back; a few pages were lost, but most of the analyzing done about the character might've survived it at least.
All I'm trying to say (and what I hope Shaddy was too) was that Ken outright admit that Locke was based off his father, and with that, you can infer that he was using the book to work through his issues. That's old news tho, and for the sake of safety, I'd say that it shouldn't be made into a big deal. Again. I admit to doing that in the past, but this topic is already on thin ice as it is.
Welcome to my horrid realization about Ken using the book as a therapist that I made, like, last year. It is pretty awful to realize when you realize that, especially when one'd been a long time reader. As for the Brotherhood, despite when Ken recently tried to claim, they were never depicted as "shades of grey" and were only intended to be absolute paragons. From excusing the attempted murder of a 10 year old ("The Brotherhood looks after their own") to abusing their 'neutrality' in the Overlander-Mobian Great War ("You best not come back here Robotnik ancestor, you or your people! Or you'll deal with... things!") to look after Elias, then flagrantly telling the world to piss off during both Robotnik Wars. Always the excuses. Speaking of Elias, I'm not to surprised that Ken's retconned Alicia as the Knothole/Mobotropolis monarch (it was either that for try to use the name "King Max" on another character), but it wouldn't be the first time he's screwed up those characters. He basically forgot that Sally was a young child when Alicia and Elias went missing, yet didn't forgot he established that and had to make another excuse when Elias was drawn as a baby at the time when he should have been at least older than 5.


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Category - Applications
Home » Mobile » Applications
Angry Birds is one of the most recognizable mobile games. It came to small screens more than a decade ago as a simple game of puzzle and aim, although over time there were incessant continuations in all possible genres...
Although WhatsApp is an application used mainly on mobile phones, for years it has also it is possible to use WhatsApp from the computer, either through the browser or from the WhatsApp Web application, something that...
Parler users move to Telegram and violent content moderation increases
A few days after the end of Donald Trump's term, those responsible for the main social networks on the planet are taking the determination to put an end to the calls for disinformation and violence of the US...
a great app to earn money answering surveys
Legendary Edition 'will come to iOS and Android in February and you can now register
WhatsApp postpones its new privacy policy until May and will combat "misinformation" and "rumors"
WhatsApp tries to stop the rout of users by explaining how privacy works in messages
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Lightning ink Cup victor Maroon to 1-year deal
Pat Maroon's St. Louis Blues career is complete after just one season, but he certainly made some unforgettable memories during his lone year with his hometown team. The 31-year-old has 88 goals and 118 assists in 449 games across his eight-year National Hockey League career. "I'm pumped to get the opportunity to play for the Bolts and I can't wait to get down there and meet my new teammates an... [Full Article...]
Virgil van Dijk set for new Liverpool FC contract
Another legendary figure was selected as the greatest Dutchman, with Van Dijk adding: "Marco van Basten". When he was asked who his best teammate has been, last season's PFA Players' Player of the Year victor responded: "I'm going to be a little bit biased and say one of my teammates; I would say Roberto Firmino ". [Full Article...]
Joe Schmidt: 'Underdone' Ireland not good enough in England defeat
Only New Zealand have inflicted a heavier defeat on Ireland , who are seeking to bring some momentum into their World Cup campaign following a lacklustre Six Nations. "James Ryan (lock), (back row forward) Jack Conan there are a few guys who could come into the picture next week", said Schmidt. "This was Ireland's first competitive game [they had beaten Italy on August 10], so we know they ... [Full Article...]
Andrew Luck Comments on Being Booed By Colts Fans After Retirement Announcement
During his senior year, he passed for 2,606 yards with 23 touchdowns and five interceptions. The son of former National Football League quarterback Oliver Luck, Andrew Luck described himself as "quite exhausted and quite tired". The oft-injured star is retiring at age 29. " Jacoby Brissett is new QB of the Colts". "It's been unceasing, unrelenting, both in-season and offseason, and I felt s... [Full Article...]
Did umpires screw Yankees in loss to Dodgers?
Gleyber Torres , who had been on second base, rounded third, watched the scene at second base, and then raced home, crossing the plate. He looked like he would score the tying run but the home plate umpire and Dodgers closer Kenley Jansen indicated time had been called. [Full Article...]
Salah nets a brace as Liverpool down Elneny's Arsenal 3-1
The Ivorian raced clear and skipped past Andy Robertson with a deft touch but his effort was sacked straight at Adrian in the Liverpool goal. Mistakes continued to come at both ends. The Egypt superstar did not have a huge impact on the first half but burst into life following the resumption. Luiz had already brought Salah down for a penalty with one of the most shameless pulls of the shirt ... [Full Article...]
Colts QB Andrew Luck is retiring from the NFL
Luck is reportedly mentally worn down after a number of injury issues in recent years. The "even if" in the above quote shows that he is prepared to start Brissett for the opening week of the regular season if Luck does not heal in time. The Colts have three other quarterbacks on their roster, including Jacoby Brissett, Phillip Walker and Chad Kelly. He has played in 20 games for the Colts over th... [Full Article...]
Rayudu Takes Retirement U-Turn, Says Will Definitely Play IPL
Rayudu, who is now taking part in TNCA League for Grand Slams, said his priority is to get back to full fitness. Asked what forced him to leave the game, Rayudu replied, "I worked for four years for the last World Cup". Rayudu, who looked in good touch during his innings of 47 for Grand Slam in their clash against Jolly Rovers on Thursday, said he was happy to be back in the city. [Full Article...]