Myocardial lead attachment system
The present invention is a myocardial lead attachment system for securing a distal end of a lead within a myocardium of a patient's heart. The system includes an anchor, a tether coupled to the anchor, and a delivery instrument for receiving and advancing the anchor through a tract in the heart from a proximal entrance site to a distal exit site in such a manner that the tether extends proximally from the anchor through the tract. The delivery instrument includes a needle having a distal tip and a nest. The nest is positioned proximal to the distal tip and is sized to receive the anchor. The delivery instrument further includes an ejection mechanism for ejecting the anchor from the nest.
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The present application claims the benefit of the following U.S. Provisional Applications: application Ser. No. 60/514,037 filed Oct. 24, 2003, entitled “Absorbable Myocardial Lead Fixation System”, application Ser. No. 60/514,665 filed Oct. 27, 2003, entitled “Lead Electrode Arrangement for Myocardial Leads”, application Ser. No. 60/514,042 filed Oct. 24, 2003, entitled “Tapered Tip for Myocardial Lead”, application Ser. No. 60/514,714 filed Oct. 27, 2003, entitled “Minimally-Invasive Fixation Systems for Over-the-Tether Myocardial Leads”, application Ser. No. 60/514,039 filed Oct. 24, 2003, entitled “Distal or Proximal Fixation of Over-the-Suture Myocardial Leads”, application Ser. No. 60/514,146 filed Oct. 24, 2003, entitled “Myocardial Lead with Fixation Mechanism”, application Ser. No. 60/514,038 filed Oct. 24, 2003 entitled “Delivery Instrument for Myocardial Lead Placement” and application Ser. No. 60/514,713 filed Oct. 27, 2003, entitled “Drug-Eluting Myocardial Leads”, all of which are incorporated herein by reference.
Reference is hereby made to the following commonly assigned U.S. patent application Ser. No. 10/821,421, filed Apr. 9, 2004, entitled “Cardiac Electrode Anchoring System” and the following commonly assigned U.S. Patent applications filed on an even date herewith, all of which are incorporated herein by reference: application Ser. No. ______, entitled “Myocardial Lead”, application Ser. No. ______ entitled “Distal or Proximal Fixation of Over-the-Tether Myocardial Leads”, application Ser. No. ______, entitled “Myocardial Lead with Fixation Mechanism” and application Ser. No. ______, entitled “Absorbable Myocardial Lead Fixation System.”
FIELD OF THE INVENTIONThis invention relates generally to implantable lead assemblies for stimulating and/or sensing electrical signals in muscle tissue. More particularly, it relates to myocardially implanted leads for cardiac stimulation and systems for anchoring the leads.
BACKGROUND OF THE INVENTIONCardiac rhythm management systems are used to treat heart arrhythmias. Pacemaker systems are commonly implanted in patients to treat bradycardia (i.e., abnormally slow heart rate). A pacemaker system includes an implantable pulse generator and leads, which form the electrical connection between the implantable pulse generator and the heart. An implantable cardioverter defibrillator (“ICD”) is used to treat tachycardia (i.e., abnormally rapid heart rate). An ICD also includes a pulse generator and leads that deliver electrical energy to the heart.
The leads coupling the pulse generator to the cardiac muscle are commonly used for delivering an electrical pulse to the cardiac muscle, for sensing electrical signals produced in the cardiac muscle, or for both delivering and sensing. The leads are susceptible to categorization according to the type of connection they form with the heart. An endocardial lead includes at least one electrode at or near its distal tip adapted to contact the endocardium (i.e., the tissue lining the inside of the heart). An epicardial lead includes at least one electrode at or near its distal tip adapted to contact the epicardium (i.e., the tissue lining the outside of the heart). Finally, a myocardial lead includes at least one electrode at or near its distal tip inserted into the heart muscle or myocardium (i.e., the muscle sandwiched between the endocardium and epicardium). Some leads have multiple spaced apart distal electrodes at differing polarities and are known as bipolar type leads. The spacing between the electrodes can affect lead performance and the quality of the electrical signal transmitted or sensed through the heart tissue.
The lead typically consists of a flexible conductor surrounded by an insulating tube or sheath that extends from the electrode at the distal end to a connector pin at the proximal end. Endocardial leads are typically delivered transvenously to the right atrium or ventricle and commonly employ tines at a distal end for engaging the trabeculae.
The treatment of congestive heart failure (“CHF”), however, often requires left ventricular stimulation either alone or in conjunction with right ventricular stimulation. For example, cardiac resynchronization therapy (“CRT”) (also commonly referred to as biventricular pacing) is an emerging treatment for heart failure, which requires stimulation of both the right and the left ventricle to increase cardiac output. Left ventricular stimulation requires placement of a lead in or on the left ventricle near the apex of the heart. One technique for left ventricular lead placement is to expose the heart by way of a thoracotomy. The lead is then positioned so that one or more electrodes contact the epicardium or are embedded in the myocardium. Another method is to advance an epicardial lead endovenously into the coronary sinus and then advance the lead through a lateral vein of the left ventricle. The electrodes are positioned to contact the epicardial surface of the left ventricle.
The left ventricle beats forcefully as it pumps oxygenated blood throughout the body. Repetitive beating of the heart, in combination with patient movement, can sometimes dislodge the lead from the myocardium. The electrodes may lose contact with the heart muscle, or spacing between electrodes may alter over time.
There is a need for an improved myocardial pacing lead suitable for chronic implantation and a minimally invasive delivery system and method for implanting such a lead.
SUMMARY OF THE INVENTIONThe present invention, according to one embodiment, is a myocardial lead attachment system for securing a distal end of a lead within a myocardium of a patient's heart. The system includes an anchor, a tether coupled to the anchor and a delivery instrument for receiving the anchor and advancing the anchor through a tract in the heart from a proximal entrance site to a distal exit site in such a manner that the tether extends proximally from the anchor through the tract. The delivery instrument includes a needle having a distal tip and a nest positioned proximal to the distal tip that is sized to receive the anchor and an ejection mechanism for ejecting the anchor from the nest.
The present invention, according to another embodiment, is a myocardial lead attachment system for securing a distal end of a lead within a myocardium of a patient's heart. The system includes an anchor having a longitudinal bore extending therethrough, a tether coupled to the anchor and a delivery instrument for receiving the anchor and advancing the anchor through a tract in the heart from a proximal entrance site to a distal exit site in such a manner that the tether extends proximally from the anchor through the tract. The delivery instrument includes a needle having a proximal end, a distal end formed with a nest for receiving the anchor and a central lumen extending therethrough. The delivery instrument further includes a stylet slidably received in the needle lumen and the anchor bore and an ejector plug formed on the stylet for engaging the anchor.
The present invention, according to another embodiment, is a method for using a delivery instrument to implant a myocardial lead having at least a first electrode with a delivery instrument into a heart. A myocardial anchor coupled to a tether. is mated to a distal end of the delivery instrument. The distal end of the delivery instrument is advanced through a tract in the heart. The anchor is deployed into the heart. The delivery instrument is withdrawn through the tract in such a manner that the tether extends through the tract. A myocardial lead is threaded onto the tether. The lead is advanced over the tether into the heart.
This summary is not intended to describe each embodiment or every implementation of the present invention. Advantages and a more complete understanding of the invention will become apparent upon review of the detailed description and claims in conjunction with the accompanying drawings.
BRIEF DESCRIPTION OF THE DRAWINGS
While the invention is amenable to various modifications and alternative forms, specific embodiments have been shown by way of example in the drawings and are described in detail below. The intention, however, is not to limit the invention to the particular embodiments described. On the contrary, the invention is intended to cover all modifications, equivalents, and alternatives falling within the scope of the invention as defined by the appended claims.
DETAILED DESCRIPTION
The outer walls of the heart 12 are lined with a tissue known as the epicardium 28. The inner walls of the heart are lined with a tissue known as the endocardium 30. The heart muscle, or myocardium 32, is sandwiched between the endocardium 30 and the epicardium 28. A tough outer pericardial sac 33 surrounds the heart 12.
The myocardial lead attachment system 10 includes a pulse generator 34 coupled to a myocardial lead 36. The pulse generator 34 is typically implanted in a pocket formed, underneath the skin of the patient's chest or abdominal region. The lead 36 extends from the pulse generator 34 to the heart 12 and is implanted in the myocardium 32 near an apex 38 of the heart 12. The lead 36 delivers electrical signals from the pulse generator 34 to an electrode located at or near a distal tip to accomplish pacing of the heart 12 (not shown in
According to one embodiment, and generally shown in the following figures, the anchor mechanism 44 is an elongated T-bar, in which the tether 45 is coupled to the anchor mechanism 44 between its opposite ends and preferably at a mid-point to form the “T”. According to other embodiments, the anchor mechanism 44 has any other shape suitable for forming an anchor against the heart 12 to retain the lead 36 in the desired location. An important feature of the anchor mechanism 44 is that its shape is configured to engage the heart tissue following implantation through a tract (not visible in
Placement of the lead 36 and anchor mechanism 44 of
The delivery instrument 50 includes a handle 52 having a proximal end 54 and a distal end 56. The needle portion 58 is coupled to the handle 52 and extends from the distal end 56. The needle portion 58 is of a hypotube construction with an internal lumen 59. The handle 52 has an internal lumen 64 continuous with the needle lumen 59. The ejection mechanism 66 is located on the handle 52 and is operable within the internal lumen 64. According to other embodiments, the ejection mechanism 66 is located elsewhere on the handle 52.
The handle 52 is sized with a length a and diameter b for easy grasping and manipulation. According to one embodiment of the present invention, a diameter b of about 5 mm provides a mechanical advantage allowing stable control over the direction of the distal needle tip 60. Further, a diameter b of about 5 mm can be used within a standard 7 mm or larger thoracic port, which is commonly used in minimally-invasive thoracoscopic procedures to access the heart 12.
An outer surface 70 of the handle 52 includes a surface feature 68. Surface feature 68 may include bumps, ribs, or bulging features on the outer surface 70 chosen to enhance the friction between the handle 58 and the surgeon's hand. Surface feature 68 advantageously reduces slippage between the surgeon's hand and the handle 52 while in wet, slippery environments. The handle 52 can be made of any sterilizable metal or polymeric material, including stainless steel, polypropylene, and polyurethane.
The shape of the distal needle portion 58 is configured to facilitate access to the heart 12 via thoracotomy or other procedures, such as those mentioned above. According to one embodiment of the present invention, the needle portion 58 is shaped with a curved portion 72. The shape of the curved portion 72 will be dictated in part by patient anatomy (e.g., overall heart size, peculiarities in geometry due to dilation, epicardial fat, infarct, and vessels), location of the thoracotomy (posterior or anterior to an imaginary mid-axillary line bisecting the heart 12), and size of the incision into the heart tissue. According to one embodiment, the curved portion 72 has a radius of curvature R72 of about 22 mm, a shape intended to be approximately what the physician would need for implanting the lead 36 via a thoracotomy. According to other embodiments, the radius of curvature R72 of curved portion 72 is from about 10 to about 35 mm (not shown). According to other embodiments, the curved portion 72 is constructed of multiple curved segments, or is straight (not shown).
According to one embodiment, the needle portion 58 is constructed of stainless steel. The curved portion 72 may be formed according to a variety of methods. The curved portion 72 may be formed by mechanically bending the needle portion 58. Alternately, the needle portion 58 is heat-set so that the needle portion 58, or a smaller portion thereof, is malleable. A chosen curvature can be imparted to the needle portion 58 contemporaneous with the implantation procedure according to the surgeon's needs.
The nest 62 is sized with a length d and a width e chosen such that the nest 62 retains the anchor mechanism 44 when the needle portion 58 is advanced through the myocardium 32 (anchor mechanism 44 not visible in FIGS. 3A and 3B—see
According to one embodiment, shown in
Returning to
According to one embodiment, the ejection mechanism 66 and actuator 84 are operable to advance the elongated member 80 to one of a plurality of pre-set positions. According to another embodiment, the present invention is an automatic or semi-automatic delivery instrument. In this embodiment a lever mechanism, or trigger and spring mechanism, drives the needle portion 58 from a retracted position into the myocardium 32 in a prescribed path, ejects the anchor mechanism 44 and retracts the needle portion 58 to its original position.
According to the present embodiment, the nest 106 is an open sleeve at a distal end of the needle 102. The anchor mechanism 108 is received in the nest 106 and protrudes outwardly from the nest 106. The needle 102 includes a crimp or detent 110 near to and proximal to the nest 106 for contacting a proximal or trailing edge 112 of the anchor mechanism 108. An inside diameter f of the nest 106 is slightly greater than an outside diameter g of the anchor mechanism 108, such that the anchor mechanism 108 can readily release from the nest 106 upon application of a relatively small force on the anchor mechanism 108 directed distally from the needle 102. The anchor mechanism 108 is coupled to a tether 113 as previously described. The needle 102 is further provided with a central lumen 114 extending therethrough.
The ejection mechanism 109 is a stylet 115 coupled to an ejection plug 116. The stylet 115 has a sharpened distal tip 117 shaped to effectively dissect the tissue of the myocardium 32. According to other embodiments, the tip 117 is blunt or rounded to reduce trauma to the myocardium 32. The stylet 115 extends through the needle lumen 114 and through a bore 118 extending longitudinally through the anchor mechanism 108. The ejector plug 116 is spherical and is sized and shaped smaller than an inside diameter h of the needle 102 at the crimp 110 so as to pass through the crimp 110 but larger than an inside diameter I of the bore 118 in the anchor mechanism 108 so as to contact the trailing edge 112 of the anchor mechanism 108. According to other embodiments, the ejector plug 116 has a cylindrical or other shape. According to still other embodiments, the ejector plug 116 is not formed integrally with the stylet 115 but rather is a separate member such as a clip that is affixed to the stylet 115.
During implantation, the anchor mechanism 108 is received in the nest 106. The tip 117 of the stylet 115 extends through the bore 118 in the anchor mechanism 108 and protrudes from the bore 118. The tube 102 and the stylet 115 are used to guide the anchor mechanism 108 through the myocardium 32. The crimp 110 contacts the trailing edge 112 of the anchor mechanism 108 to force the anchor mechanism 108 through the myocardium 32. Once the anchor mechanism 108 emerges from the myocardium 32, the ejection mechanism 109 is actuated by advancing the stylet 115 distally with respect to the tube 102, such that the ejection plug 116 contacts the trailing end 112 of the anchor mechanism 108 and ejects the anchor mechanism 108 from the nest 106. This deploys the anchor mechanism 108 on the surface of the heart 12. The needle 102 and stylet 115 are then withdrawn.
According to one embodiment, the ejection mechanism 109 is coupled to an actuator as described with respect to the embodiment shown generally in
The stylet 126 is provided with an ejector plug 136 as described previously. According to the present embodiment, however, the ejector plug 136 is cylindrical in shape. According to the embodiment shown, the anchor mechanism 128 includes an angled or tapered leading edge 138. Tapered edge 138 facilitates dissection of the myocardium 32 during implantation. The leading edge 138 of the anchor mechanism 128 may have a blunt or rounded profile similar to the profile of the needle tip 60 described with reference to the embodiment shown in
The instrument 160 is advanced through the heart 12, and the stylet 162 is manipulated into the heart 12 and position the anchor mechanism 164. When the anchor mechanism 164 has been properly positioned, the stylet 162 is withdrawn.
The catch mechanism 210 has an inner diameter smaller than an outside diameter n of the stylet 202, such that the stylet tip 208 can be inserted partially into the catch mechanism 210, but the stylet 202 cannot fully pass through the catch mechanism 210. The stylet tip 202 is inserted into the catch mechanism .210 so that the anchor 204 lies adjacent the length of the stylet 202. According to other embodiments, the stylet 202 is provided with a circumferential groove for receiving the catch mechanism 210 (not shown). The stylet 202 is inserted into the myocardium 32, drawing the anchor mechanism 204 along via the catch mechanism 210. Once the stylet tip 208 and the anchor mechanism 204 emerge from the myocardium 32, the stylet 202 is withdrawn, disengaging from the catch mechanism 210. Following implantation, the catch mechanism 210 may be removed or may be left in place.
The needle 304 is electrically exposed at a distal tip 312 and at a proximal region 314. The proximal exposed region 314 is accessible via a cut-out or window 316 formed in the handle 302. The needle 304 acts as an electrical conductor between the exposed proximal region 314 and the exposed distal tip 312. Alligator clips or other electrical connectors may be coupled to the needle 304 through the window 316 to electrically couple the exposed distal tip 312 to a pacing and sensing analyzer for performing sensing and pacing functions (not shown).
The exposed area at tip 312 is brought into contact with the epicardium 28 or myocardium 32 to perform sensing and pacing functions prior to ejection of the myocardial anchor 306. Additionally, acute therapeutic benefit at a particular site may be assessed using said embodiment. If acute benefit is unacceptable, the implant site may be changed prior to implanting the lead 36.
The systems shown in
A target region of the heart 12 is approached and advanced sensing probes may be used to assess the suitability of the location. This assessment may include typical measurements such as pacing thresholds, sensing amplitudes, and tissue impedance. These functions may be accomplished with a delivery instrument in accordance with the embodiments shown in
After a determination that the location is suitable for lead implantation, an anchor mechanism 44 as is shown in
Once the delivery instrument 50 emerges through the epicardium 28 (or the endocardium 30, pericardium 33, or myocardium 32), the ejection mechanism 66 is activated to dislodge the anchor mechanism 44 from the nest 62. The delivery instrument 50 is then withdrawn back through the tract 37 and removed. The tether 45 is then tensioned to cause the anchor 44 to engage against the epicardium 28 (or endocardium 30, pericardium 33 or myocardium 32).
According to other embodiments (see
According to still other embodiments (see
Following delivery of the anchor mechanism 44 to the epicardial surface 28 (or the myocardium 32, the endocardial surface 30 or the pericardial surface 33) according to any of the aforementioned embodiments, the tether 45 is tensioned and the lead 36 advanced as described above. Following implantation of the myocardial lead 36, the tether 45 is tensioned and secured to the myocardial lead 36 to secure the myocardial lead 36 within the myocardium 32. According to other embodiments, the myocardial lead 36 is provided with additional means to secure the myocardial lead 36 within the myocardium 32 following delivery.
The lead 36 is positioned in the heart 12 and anchored, as described above, to position the lead electrode 40 in chosen locations in the heart 12. Although generally shown in implanted near the apex 38, the lead 36 may be implanted anywhere in the heart pacing therapy is needed. For example, the lead 36 may be implanted in the free wall of the left ventricle 20. According to one embodiment, shown in
In one embodiment, the cathode 40b has an active electrode surface area of about 1 square mm. The cathode 40b is located near the distal tip 35 of the lead body 36. An electrode spacing between the cathode 40b and anode 40a of more than about 2 cm would generate a unipolar lead, as defined above. An electrode spacing of between about 1 and about 2 cm would generate a pseudo-unipolar lead, as defined above. An electrode spacing of less than about 1 cm would generate a bipolar lead, as defined above.
In the epicardium to epicardium configuration, the epicardium to endocardium configuration and the intramyocardial configuration, once implanted, the lead body 36 will serve to block the tract in the myocardium 32 created by the delivery instrument 50 and prevent further loss of blood from the heart 12. If it becomes necessary to reposition the lead 36 and create a second tract, a porous, clot-promoting “plug” material can be fed over the tether 45 into the tract 37 to serve as a seal. Following implantation of the myocardial lead 36, the tether 45 is tensioned and secured to the myocardial lead 36 to secure the myocardial lead 36 within the myocardium 32.
Various modifications and additions can be made to the exemplary embodiments discussed without departing from the scope of the present invention. Accordingly, the scope of the present invention is intended to embrace all such alternative, modifications, and variations as fall within the scope of the claims, together with all equivalents thereof.
Claims
1. A myocardial lead attachment system for securing a distal end of a lead within a myocardium of a patient's heart, the system comprising:
- an anchor;
- a tether coupled to the anchor; and
- a delivery instrument for receiving and advancing the anchor through a tract in the heart from a proximal entrance site to a distal exit site in such a manner that the tether extends proximally from the anchor through the tract, said delivery instrument comprising: a needle having a distal tip and a nest positioned proximal to the distal tip and sized to receive the anchor, and an ejection mechanism for ejecting the anchor from the nest.
2. The lead attachment system of claim 1 wherein the ejection mechanism further comprises an actuator for ejecting the anchor from the nest.
3. The lead attachment system of claim 1 wherein a distal portion of the needle is formed with a radial curvature.
4. The lead attachment system of claim 2 wherein the ejection mechanism further comprises an elongated member slidable from a retracted position to an extended position in response to actuation of the actuator to engage the anchor mechanism.
5. The lead attachment system of claim 4 further comprising:
- a mechanical stop for limiting extension of the elongated member; and
- a resilient member biasing the actuator to retract the elongated member.
6. The lead attachment system of claim 1 wherein the delivery instrument further comprises:
- a distal electrically active area on the needle; and
- a conductive member for connecting the electrically active area to an external electrical device.
7. The lead attachment system of claim 1 wherein the nest further includes a slot for receiving the tether.
8. The lead attachment system of claim 1 wherein the nest includes a ramp adapted to assist in ejection of the anchor.
9. The lead attachment system of claim 1 further comprising a lead body having a proximal end, a distal end, and at least a first electrode near the distal end, said lead body adapted to advance over the tether through the tract.
10. The lead attachment system of claim 9 wherein the lead body is a unipolar lead.
11. The lead attachment system of claim 10 wherein the lead body includes a second electrode spaced apart the first electrode apart by about at least 2 cm.
12. The lead attachment system of claim 9 wherein the lead body is a pseudo-unipolar lead.
13. The lead attachment system of claim 9 wherein the lead body is a bipolar lead.
14. A myocardial lead attachment system for securing a distal end of a lead within a myocardium of a patient's heart, the system comprising:
- an anchor having a longitudinal bore extending therethrough;
- a tether coupled to the anchor; and
- a delivery instrument for receiving and advancing the anchor through a tract in the heart from a proximal entrance site to a distal exit site in such a manner that the tether extends proximally from the anchor through the tract, said delivery instrument comprising: a needle having a proximal end, a distal end formed with a nest for receiving the anchor and a central lumen extending therethrough; a stylet slidably received in the needle lumen and the anchor bore, and an ejector plug formed on the stylet for engaging the anchor.
15. The lead attachment system of claim 14 wherein the nest is an open sleeve at the distal end of the needle.
16. The lead attachment system of claim 15 wherein the nest has an internal stop for transmitting an axial force to the anchor.
17. The lead attachment system of claim 15 wherein the anchor has a proximal region sized to be received in the nest and a distal region sized to be retained outside of the nest.
18. The lead attachment system of claim 15 wherein the anchor has a tapered distal face shaped to dissect the tissue of the myocardium.
19. The lead attachment system of claim 14 wherein the stylet has a pointed distal end shaped to dissect the tissue of the myocardium.
20. A method for using a delivery instrument to implant a myocardial lead into the heart, said lead having at least a first electrode, the method comprising:
- mating a myocardial anchor coupled to a tether to a distal end of the delivery instrument;
- advancing the distal end of the delivery instrument through a tract in the heart;
- deploying the anchor into the heart;
- withdrawing the delivery instrument through the tract in such a manner that the tether extends through the tract;
- threading a myocardial lead onto the tether; and
- advancing the lead over the tether into the heart.
21. The method of claim 20 further comprising:
- advancing the anchor through the epicardium, into the myocardium, and back through the epicardium; and
- deploying the anchor mechanism on the epicardial surface.
22. The method of claim 20 further comprising:
- advancing the anchor through the epicardium, into the myocardium and through the endocardium; and
- deploying the anchor on the endocardial surface.
23. The method of claim 20 further comprising:
- advancing the anchor through the epicardium and into the myocardium; and
- deploying the anchor into the myocardium.
24. The method of claim 20 further comprising:
- advancing the anchor into the pericardium and out of the pericardium without traversing the epicardium; and
- deploying the anchor on the pericardial surface.
25. The method of claim 20 further comprising advancing the lead body until the first electrode is in contact with the heart.
26. The method of claim 20 further comprising advancing the lead body until the first electrode is in contact with the myocardium.
27. The method of claim 26 wherein the lead body includes a second electrode proximal to the first electrode and further comprising advancing the lead body until the second electrode is at least partially in contact with the heart.
28. The method of claim 27 further comprising advancing the lead body until the second electrode straddles the epicardium.
29. The method of claim 27 further comprising advancing the lead body until the second electrode is in contact with the myocardium.
30. The method of claim 20 further comprising:
- forming a working channel and a visual channel to the heart with an endoscopic probe; and
- advancing the anchor and delivery instrument to the heart through the working channel.
Type: Application
Filed: Oct 22, 2004
Publication Date: May 26, 2005
Applicant: Cardiac Pacemakers, Inc. (St. Paul, MN)
Inventors: M. Sean Coe (Plymouth, MN), Ronald Heil (Roseville, MN), Peter Kelley (Buffalo, MN), Jason Shiroff (Shoreview, MN), Randy Westlund (River Falls, WI), Donald Palme (Princeton, MN), Charles Gresl (San Francisco, CA)
Application Number: 10/971,551