Systems, apparatuses, and methods for delivery of ablation energy to tissue

Abstract

To provide a system including a pulse waveform generator and an ablation device coupled to the pulse waveform generator.SOLUTION: An ablation device includes at least one electrode configured for ablation pulse delivery to tissue during use. A pulse waveform generator is configured to deliver voltage pulses to the ablation device in a form of a pulsed waveform. A first level of a hierarchy of the pulsed waveform includes a first set 121 of pulses, each pulse having a pulse time duration, with a first time interval 118 separating successive pulses. A second level of the hierarchy of the pulsed waveform includes a plurality of first sets of pulses as a second set 122 of pulses, a second time interval 119 separating successive first sets of pulses, the second time interval being at least three times the duration of the first time interval.SELECTED DRAWING: Figure 3

Description

[Technical field]

[0001] CROSS-REFERENCE TO RELATED APPLICATIONS This application claims priority to U.S. Provisional Patent Application No. 62 / 274,926, entitled "SYSTEMS, APPARATUSES AND DEVICES FOR DELIVERY OF PULSED ELECTRIC FIELD ABLATIVE ENERGY TO ENDOCARDIAL TISSUE," filed January 5, 2016, the entire disclosure of which is incorporated herein by reference in its entirety. [Background technology]

[0002] While the effects of short pulses of high voltage and large electric fields on tissues have been explored for over 40 years, the generation of pulsed electric fields for tissue therapy has only moved from the laboratory to clinical applications over the past 20 years. The application of short high DC voltages to tissues, which can generate localized high electric fields, typically in the range of several hundred volts / centimeter, can disrupt cell membranes by generating pores in the cell membrane. While the exact mechanism of this electrogenic pore generation or electroporation is unclear, it is believed that the application of relatively large electric fields generates instability in the lipid bilayer in the cell membrane, generating a distribution of localized gaps or pores in the membrane. If the electric field applied at the membrane is higher than a threshold, the electroporation can be irreversible and the pores remain open, allowing the exchange of biomolecular material across the membrane, resulting in necrosis and / or apoptosis (cell death). The surrounding tissue then heals by natural processes.

[0003] Thus, known electroporation application and delivery methods in medicine do not address high voltage application, tissue selectivity, and safe energy delivery, particularly in the context of ablation therapy for cardiac arrhythmias with catheter devices. Additionally, there is an unmet need for thin, flexible, atraumatic devices that can effectively deliver high DC voltage electroporation ablation therapy selectively to tissue in targeted areas while simultaneously minimizing damage to healthy tissue, and an unmet need for device design and administered waveform combinations that allow for effective, safe, and rapid clinical procedures with minimal or no device repositioning. Summary of the Invention

[0004] The system includes a pulse waveform generator and an ablation device coupled to the pulse waveform generator. The ablation device includes at least one electrode configured for delivering ablation pulses to tissue when in use. The pulse waveform generator is configured to deliver voltage pulses to the ablation device in the form of a pulsed waveform. A first level hierarchy of pulsed waveforms includes a first set of pulses, each pulse having a pulse duration, with a first time interval separating successive pulses. A second level hierarchy of pulsed waveforms includes a plurality of first sets of pulses as a second set of pulses, with a second time interval separating successive first sets of pulses, with the second time interval being at least three times the duration of the first time interval. [Brief description of the drawings]

[0005] [Figure 1] FIG. 2 is a schematic diagram of a catheter with multiple electrodes disposed along its distal shaft, positioned epicardially such that the catheter is wrapped snugly around the pulmonary veins of the cardiac anatomy, according to an embodiment. [Diagram 2] FIG. 2 is a diagram showing an example waveform showing a series of voltage pulses with a defined pulse width for each pulse, according to an embodiment. [Diagram 3]FIG. 2 is a schematic illustrating a hierarchy of pulses showing pulse widths, spacing between pulses, and pulse groupings, according to an embodiment. [Figure 4] FIG. 1 is a schematic diagram of a nested hierarchy of monophasic pulses showing different levels of nested hierarchy according to an embodiment. [Diagram 5] FIG. 2 is a schematic diagram of a nested hierarchy of biphasic pulses showing different levels of the nested hierarchy according to an embodiment. [Figure 6] FIG. 13A is a schematic diagram illustrating numbered catheter electrode rings from which a set of electrodes can be sequentially selected for application of a corresponding succession of voltage pulse waveforms, according to an embodiment. [Figure 7] FIG. 10 is a schematic diagram illustrating a time sequence of an electrocardiogram and a cardiac pacing signal along with both atrial and ventricular refractory periods indicating a time window for irreversible electroporation ablation, according to an embodiment. [Figure 8] FIG. 13A is a schematic diagram illustrating the time sequence of activation of a set of electrodes delivered as a series of waveform packets over a corresponding series of consecutive heart beats, according to an embodiment. [Figure 9] FIG. 1 is a schematic diagram of an irreversible electroporation system including a system console including, in turn, a voltage / signal generator, a controller configured to apply voltage to a selected subset of the electrodes communicatively connected to a computer or processor along with a user interface, and a switching unit configured to electrically isolate other equipment from voltage pulses that may be delivered from the voltage generator to the ablation catheter, according to an embodiment. [Figure 10] FIG. 2 illustrates a user interface in an initial configuration, according to an embodiment. [Figure 11] 11 is a schematic diagram of a user interface showing engagement of an initialization function according to an embodiment. [Figure 12] FIG. 2 is a schematic diagram of a user interface showing the necessary steps following initialization according to an embodiment. [Figure 13]1 is a schematic diagram of a user interface showing a configuration in which the system is ready to deliver ablation energy following completion of the previous steps, in which the user interface includes a button for ablation according to an embodiment. DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0006] The terms "about" and "approximately," when used herein in conjunction with a reference numerical designation, mean the reference numerical designation plus or minus up to 10% of the reference numerical designation. For example, the language "about 50" units or "approximately 50" units means between 45 units and 55 units.

[0007] In some embodiments, the system includes a pulse waveform generator and an ablation device coupled to the pulse waveform generator. The ablation device includes at least one electrode configured to deliver ablation pulses to tissue when in use. The pulse waveform generator is configured to deliver voltage pulses to the ablation device in the form of a pulsed waveform. A first level hierarchy of pulsed waveforms includes a first set of pulses, each pulse having a pulse duration, and a first time interval separating successive pulses. A second level hierarchy of pulsed waveforms includes a set of multiple first pulses as a second set of pulses, and a second time interval separating successive first sets of pulses, and the second time interval is at least three times the duration of the first time interval. A third level hierarchy of pulsed waveforms includes a set of multiple second pulses as a third set of pulses, and a third time interval separating successive second sets of pulses, and the third time interval is at least 30 times the duration of the second time interval.

[0008] In some embodiments, each first pulse of the set of pulses includes a monophasic pulse with a voltage amplitude of at least 800 V. In some embodiments, each monophasic pulse has a pulse duration in the range of about 1 microsecond to about 300 microseconds.

[0009] In some embodiments, each of the first pulses in the set of pulses includes a biphasic pulse with a voltage amplitude of at least 800 V. In some embodiments, each of the biphasic pulses has a pulse duration in the range of about 0.5 nanoseconds to about 20 microseconds.

[0010] In some embodiments, each second set of pulses includes at least 2 sets of first pulses and fewer than 40 sets of first pulses. In some embodiments, each third set of pulses includes at least 2 sets of second pulses and fewer than 30 sets of second pulses. In some embodiments, the second time interval is at least 10 times the duration of a pulse.

[0011] In some embodiments, the ablation device includes an ablation catheter configured for epicardial placement.In some embodiments, the ablation device includes an ablation catheter configured for endocardial placement.

[0012] In some embodiments, the system includes a pulse waveform generator and an ablation device coupled to the pulse waveform generator, the ablation device including at least one electrode configured to deliver an ablation pulse when in use. The pulse waveform generator is configured to deliver voltage pulses to the ablation device in the form of a pulsed waveform. A first level hierarchy of pulsed waveforms includes a first set of pulses, each pulse having a pulse duration, and a first time interval separating successive pulses. A second level hierarchy of pulsed waveforms includes a set of a plurality of first pulses as a second set of pulses, and a second time interval separating successive first set of pulses. In some embodiments, the second time interval is at least three times the duration of the first time interval. A third level hierarchy of pulsed waveforms includes a set of a plurality of second pulses as a third set of pulses, and a third time interval separating successive second set of pulses. In some embodiments, the third time interval is at least 30 times the duration of the second time interval. The pulse waveform generator is configured to apply multiple sets of third pulses to the ablation device with a time delay of at most about 5 milliseconds between successive sets of third pulses applied across different sets of electrodes.

[0013] In some embodiments, the ablation device includes an ablation catheter configured for epicardial placement, hi some embodiments, the ablation catheter includes at least four electrodes.

[0014] In some embodiments, each second set of pulses includes at least 2 first sets of pulses and fewer than 40 first sets of pulses. In some embodiments, each third set of pulses includes at least 2 second sets of pulses and fewer than 30 second sets of pulses. In some embodiments, each first set of pulses has a voltage amplitude of at least 800 volts.

[0015] In some embodiments, the system includes a pulse waveform generator and an ablation device coupled to the pulse waveform generator, the ablation device including at least one electrode configured, in use, to deliver an ablation pulse to tissue. The system also includes a cardiac stimulation device coupled to the pulse waveform generator, the cardiac stimulation device configured, in use, to generate a pacing signal for cardiac stimulation. The pulse waveform generator is configured to deliver voltage pulses to the ablation device in the form of a pulsed waveform, the pulsed waveform synchronized with the pacing signal. A first level hierarchy of pulsed waveforms includes a first set of pulses, each pulse having a pulse duration, and a first time interval separating successive pulses. A second level hierarchy of pulsed waveforms includes a set of a plurality of first pulses as a set of second pulses, and a second time interval separating successive first sets of pulses. A third level hierarchy of pulsed waveforms includes a set of a plurality of second pulses as a set of third pulses, and a third time interval separating successive second sets of pulses. The pulse waveform generator is configured to generate a pulsed waveform, wherein each of the first set of pulses and each of the second set of pulses, a plurality of second pulse sets, a predetermined number of electrode sets, a time delay, a pulse duration, a first time interval, a second time interval, and a third time interval are jointly constrained by a Diophantine inequality.

[0016] In some embodiments, the Diophantine inequality constraint is further characterized by a refractory time window.In some embodiments, the number of the first sets of pulses and the number of the second sets of pulses are predetermined.

[0017] In some embodiments, the pulse waveform generator is further configured to deliver the pulsed waveform spaced from the pacing signal by a time offset, the time offset being less than about 25 milliseconds. In some embodiments, the third time interval corresponds to a pacing period associated with the pacing signal. In some embodiments, the second time interval is at least three times the duration of the first time interval. In some embodiments, the third time interval is at least 30 times the duration of the second time interval. In some embodiments, the second level time interval is at least 10 times the duration of the time duration of the pulse.

[0018] In some embodiments, the ablation device includes an ablation catheter configured for epicardial placement.In some embodiments, the ablation device includes an ablation catheter configured for endocardial placement.

[0019] In some embodiments, the system includes a pulse waveform generator including a user interface and an ablation device coupled to the pulse waveform generator, the ablation device including a plurality of electrodes configured, in use, for delivering ablation pulses to tissue of a patient. The system also includes a cardiac stimulation device coupled to the pulse waveform generator, the cardiac stimulation device configured, in use, for generating a pacing signal for cardiac stimulation. The pulse waveform generator is configured to deliver voltage pulses to the ablation device in the form of a pulsed voltage waveform having at least three levels of hierarchy. The pulse waveform generator is further configured to deliver the pulsed voltage waveform in synchronization with the pacing signal and to deliver the pulsed voltage waveform upon receipt of a user confirmation indication.

[0020] In some embodiments, the first level hierarchy of pulsed waveforms includes a first set of pulses, each pulse having a pulse duration, and a first time interval separating successive pulses. In some embodiments, the second level hierarchy of pulsed waveforms includes a plurality of first sets of pulses as a second set of pulses, and a second time interval separating successive first sets of pulses. In some embodiments, the third level hierarchy of pulsed waveforms includes a plurality of second sets of pulses as a third set of pulses, and a third time interval separating successive second sets of pulses. In some embodiments, the pulse waveform generator is further configured to apply a plurality of third sets of pulses to a predetermined number of electrode sets of the ablation device with a time delay between successive third sets of pulses. In some embodiments, each of the first set of pulses and each of the second set of pulses, the predetermined number of electrode sets, the time delay, the pulse duration, the first time interval, the second time interval, and the third time interval are jointly constrained by a Diophantine inequality.

[0021] In some embodiments, the pulse waveform generator is configured to deliver the pulsed waveform only after a predetermined time interval following user confirmation indication. In some embodiments, the user interface includes a control input device, and the pulse waveform generator is configured to deliver the pulsed waveform upon user engagement of the control input device.

[0022] In some embodiments, the method includes generating a pulsed waveform. The pulsed waveform includes a first level hierarchy of pulsed waveforms including a first set of pulses, each pulse having a pulse duration, and a first time interval separating successive pulses. The pulsed waveform also includes a second level hierarchy of pulsed waveforms including a plurality of the first set of pulses as a second set of pulses, and a second time interval separating successive first sets of pulses, and the second time interval is at least three times the duration of the first time interval. The pulsed waveform includes a third level hierarchy of pulsed waveforms including a plurality of the second set of pulses as a third set of pulses, and a third time interval separating successive second sets of pulses, and the third time interval is at least 30 times the duration of the second level time interval. The method also includes delivering the pulsed waveform to an ablation device.

[0023] In some embodiments, the method includes generating a pulsed waveform. The pulsed waveform includes a first level hierarchy of pulsed waveforms including a first set of pulses, each pulse having a pulse duration, and a first time interval separating successive pulses. The pulsed waveform also includes a second level hierarchy of pulsed waveforms including a plurality of the first set of pulses as a second set of pulses, and a second time interval separating successive first set of pulses, and the second time interval is at least three times the duration of the first time interval. The pulsed waveform includes a third level hierarchy of pulsed waveforms including a plurality of the second set of pulses as a third set of pulses, and a third time interval separating successive second set of pulses, and the third time interval is at least 30 times the duration of the second level time interval. The method also includes generating a pacing signal by the cardiac stimulation device. The method also includes delivering the pulsed waveform to the ablation device in synchronization with the pacing signal.

[0024] Disclosed herein are methods, systems and devices for selectively and rapidly applying pulsed electric fields / waveforms to achieve tissue ablation by irreversible electroporation. Some embodiments are directed to pulsed high voltage waveforms along with sequenced delivery schemes for delivering energy to tissue via a set of electrodes. In some embodiments, the electrodes are catheter-based electrodes or multiple electrodes arranged along the entire length of an elongated medical instrument. In some embodiments, a system useful for irreversible electroporation includes a voltage / signal generator and a controller that can be configured to apply pulsed voltage waveforms to selected multiple electrodes or a subset of electrodes of an ablation device. In some embodiments, the controller is configured to control inputs that can sequentially initiate selected pairs of anode-cathode subsets of electrodes based on a predefined sequence, and in one embodiment, the sequenced delivery can be initiated from a cardiac stimulation device or a pacing system / device. In some embodiments, the ablation pulse waveform is applied during the refractory period of the cardiac cycle to avoid disruptions in cardiac rhythm regularity. One example of how this can be done is to electrically pace the heart with a cardiac stimulating device to ensure pacing capture to establish periodicity and predictability of the cardiac cycle, and then define a time window well within the refractory period of this periodic cycle within which an ablation waveform is delivered.

[0025] In some embodiments, the pulsed voltage waveforms disclosed herein are hierarchical in order and have a nested structure. In some embodiments, the pulsed waveforms include hierarchical groupings of pulses with different associated time scales. Furthermore, the associated time scales and pulse widths, as well as the number of pulses and hierarchical groupings, can be selected to satisfy one or more of a set of Diophantine inequalities that include the frequency of cardiac pacing.

[0026] Pulsed waveforms for electroporation energy delivery as disclosed herein can enhance the safety, efficiency and effectiveness of energy delivery by lowering the electric field threshold associated with irreversible electroporation, allowing for more effective ablation lesions with reduced total energy delivered, which in turn can broaden the scope of clinical applications of electroporation, including the therapeutic treatment of various cardiac arrhythmias.

[0027] The present disclosure addresses the need for devices and methods for rapid, selective and safe delivery of irreversible electroporation therapy, generally with multiple devices, so that in some embodiments, peak electric field values ​​can be reduced and / or minimized while simultaneously maintaining a sufficiently large electric field magnitude in the area where tissue ablation is desired, which also reduces the likelihood of excessive tissue damage or arcing and localized high temperature rise.

[0028] Figure 1 is a schematic diagram of a catheter 15 with multiple electrodes disposed along its shaft. The catheter is shown in Figure 1 in relation to a heart 7, and the catheter 15 has electrodes, indicated by black bands (e.g., indicated by reference character 17 in Figure 1), wrapped epicardially around the left atrial pulmonary veins, indicated by reference characters 10, 11, 12 and 13 (top left, bottom left, top right and bottom right in Figure 1, respectively), wrapped curvilinearly and / or looped around the left atrial pulmonary veins 10, 11, 12, 13. In some embodiments, the catheter ends 8 and 9 are drawn tight together and held in a scintigraphy tool (not shown) to ensure that the catheter electrodes are wrapped snugly around the pulmonary veins 10, 11, 12, 13. Methods and apparatus for achieving placement of a multi-electrode ablation catheter surrounding a pulmonary vein using a subxiphoid pericardial access location and a guidewire-based delivery method were described in PCT Patent Application Publication No. WO2014 / 025394, entitled "Catheters, Catheter Systems and Methods for Puncturing Through a Tissue Structure and Ablating a Tissue Region," which is incorporated herein by reference in its entirety.

[0029] In some embodiments, the electrodes 17 of the catheter can be constructed in the form of metal bands or rings. In some embodiments, each electrode 17 can be constructed to be flexible. For example, the electrodes 17 can be in the form of a coiled spring or helical winding of metal around the shaft of the catheter 15. As another example, the electrode(s) 17 can be in the form of a series of metal bands or rings that are disposed along the shaft and electrically connected together to a flexible section of the catheter shaft between the electrodes that provides flexibility to the electrodes as a whole. In some embodiments, at least some of the electrodes 17 can comprise a biocompatible metal, such as, but not limited to, titanium, palladium, silver, platinum and / or platinum alloys. In some embodiments, at least some of the electrodes 17 can comprise platinum and / or platinum alloys. In some embodiments, the shaft of the catheter can be made of a flexible polymeric material, such as, for example (by way of non-limiting example only), polytetrafluoroethylene, a polyamide such as nylon, or a polyether block amide. Electrodes 17 may be connected to insulated electrical leads (not shown) that lead to a proximal handle portion (not shown) of catheter 15, the insulation on each of the leads being capable of sustaining a potential difference of at least 700 V across its thickness without dielectric breakdown. While catheter 15 is placed epicardially as shown in Figure 1, i.e., beneath the pericardium, in alternative embodiments, the ablation catheter may also or instead be useful for endocardial placement.

[0030] FIG. 2 illustrates a pulsed voltage waveform in the form of a series of square double pulses, with each pulse, such as pulse 101, associated with a pulse width or duration. The pulse width / duration can be about 0.5 microseconds, about 1 microseconds, about 5 microseconds, about 10 microseconds, about 25 microseconds, about 50 microseconds, about 100 microseconds, about 125 microseconds, about 140 microseconds, about 150 microseconds, including all values ​​and subranges therebetween. The pulsed waveform of FIG. 2 illustrates a series of monophasic pulses where the polarity of all pulses is the same (all positive in FIG. 2 measured from a baseline of zero). In some embodiments, for example, for irreversible electroporation applications, the height of each pulse 101 or the voltage amplitude of pulse 101 can be about 400 volts, about 1000 volts, about 5000 volts, about 10,000 volts, about 15,000 volts, including all values ​​and subranges therebetween. 2, pulses 101 are separated from neighboring pulses by a time interval 102, which may also be referred to as a first time interval. The first time interval can be about 10 microseconds, about 50 microseconds, about 100 microseconds, about 200 microseconds, about 500 microseconds, about 800 microseconds, about 1 millisecond, including all values ​​and subranges therebetween, to produce irreversible electroporation.

[0031] FIG. 3 introduces a pulse waveform with a structure of a hierarchy of nested pulses. FIG. 3 shows a series of monophasic pulses such as pulses 115 with pulse width / pulse duration w separated by a time interval such as 118 of duration t1 between successive pulses (also referred to as a first time interval), a number m1 of which are arranged to form a group of pulses 121 (also referred to as a first set of pulses). Furthermore, the waveform has a number m2 of such groups of pulses (also referred to as a second set of pulses) separated by a time interval 119 of duration t2 between successive groups (also referred to as a second time interval). The collection of m2 such pulse groups, marked by 122 in FIG. 3, constitutes the next level of the hierarchy, which may be referred to as a packet of pulses and / or a third set. Both the pulse width and the time interval between pulses t1 may be in the range of microseconds to hundreds of microseconds, including all values ​​and subranges therebetween. In some embodiments, the time interval t2 may be at least three times larger than the time interval t1. In some embodiments, the ratio t2 / t1 can be in the range of between about 3 and about 300, including all values ​​and subranges therebetween.

[0032] FIG. 4 further details the structure of the nested pulse hierarchy waveform. In this figure, a series of m1 pulses (individual pulses not shown) form a group 130 of pulses (e.g., a first set of pulses). A series of m2 such groups separated by an inter-group time interval 142 (e.g., a second time interval) of duration t2 between one group and the next form a packet 132 (e.g., a second set of pulses). A series of m3 such groups separated by a time interval 142 (e.g., a third time interval) of duration t3 between one packet and the next form a next level in the hierarchy, a superpacket (e.g., a third set of pulses), labeled 134 in the figure. In some embodiments, the time interval t3 may be at least 30 times greater than the time interval t2. In some embodiments, the time interval t3 may be at least 50 times greater than the time interval t2. In some embodiments, the ratio t3 / t2 may be in the range between about 30 and about 800, including all values ​​and subranges therebetween. The magnitude of the individual voltage pulses in the hierarchy of pulses can be anywhere in the range of 500 volts to over 7,000 volts, including all values ​​and subranges therebetween.

[0033] FIG. 5 provides an example of a series of biphasic waveforms with a hierarchical structure. In the illustrated example, a biphasic pulse such as 151 has a positive voltage portion as well as a negative voltage portion to complete one cycle of the pulse. There is a time delay 152 (e.g., a first time interval) between adjacent cycles of duration t1, and n1 such cycles form a group 153 of pulses (e.g., a first set of pulses). A series of n2 such groups separated by a time interval 156 (e.g., a second time interval) between the groups of duration t2 between one group and the next group forms a packet 158 ​​(a second set of pulses). The figure also shows a second packet 162 with a time delay 160 (e.g., a third time interval) of duration t3 between the packets. Just as for the monophasic pulse, further higher levels of the hierarchical structure can be formed as well. The magnitude or voltage amplitude of each pulse of a biphasic pulse can be anywhere in the range of 500 volts to 7,000 volts or more, including all values ​​and subranges therebetween. The pulse width / duration of the pulses can range from nanoseconds or sub-nanoseconds to tens of microseconds, while the delay t1 can range from zero to several microseconds. The time interval t2 between groups can be at least 10 times greater than the pulse width. In some embodiments, the time interval t3 can be at least about 20 times greater than the time interval t2. In some embodiments, the time interval t3 can be at least 50 times greater than the time interval t2.

[0034] The embodiments disclosed herein include waveforms that are structured as hierarchical waveforms that include waveform elements / pulses at various levels of hierarchy. Individual pulses, such as 115 in FIG. 3, constitute a first level of hierarchy and have an associated pulse duration and a first time interval between successive pulses. Sets of pulses or elements of the first level structure form a second level of hierarchy, such as a group of pulses / second set of pulses 121 in FIG. 3. Among other parameters associated with the waveforms are the total duration of the second set of pulses (not shown), the total number of first level elements / sets of first pulses, and the second time interval between successive first level elements that describe the second level structure / set of second pulses. In some embodiments, the total duration of the second set of pulses can be between about 20 microseconds and about 10 milliseconds, including all values ​​and subranges therebetween. Sets of groups, sets of second pulses, or elements of the second level structure form a third level of hierarchy, such as, for example, a packet of groups / third set of pulses 122 in FIG. 3. Among other parameters are the total time duration of the third set of pulses (not shown), the total number of second level elements / second set of pulses, and the third time interval between successive second level elements describing the third level structure / third set of pulses. In some embodiments, the total duration of the third set of pulses can be between about 60 microseconds and about 200 milliseconds, including all values ​​and subranges therebetween. In general, the repeating or nested structure of the waveform can continue to even higher levels, for example, up to 10 or more levels of structure.

[0035] In some embodiments, hierarchical waveforms with nested structures and time interval hierarchies as described herein are useful for delivery of irreversible electroporation ablation energy and provide a good degree of control and selectivity for application in different tissue types. Various hierarchical waveforms can be generated by a suitable pulse generator. It should be noted that while the examples herein specify separate monophasic and biphasic waveforms for clarity, combination waveforms can also be generated / implemented in which some portions of the waveform hierarchy are monophasic, while other portions are biphasic.

[0036] In embodiments directed to cardiac ablation therapy, the pulse waveforms described above may be applied by an electrode bipole selected from a set of electrodes on a catheter, such as an ablation catheter. A subset of the electrodes of the catheter may be selected as anodes while another subset of the electrodes of the ablation catheter may be selected as cathodes, with the electrode waveform being applied between the anode and cathode. As a non-limiting example, in an example where the ablation catheter is an epicardially placed ablation catheter, the catheter may be wrapped around a pulmonary vein, with one electrode selected as the anode and another electrode selected as the cathode. FIG. 6 illustrates an example annular catheter configuration, where approximately diametrically opposed electrode pairs (e.g., electrodes 603 and 609, electrodes 604 and 610, electrodes 605 and 611, and electrodes 606 and 612) may be operated as an anode-cathode set. Any of the disclosed pulse waveforms may be applied gradually or sequentially to a series of such electrode sets. As a non-limiting example, FIG. 6 depicts activation of a series of electrode subsets. As a first step, electrodes 603 and 609 are selected as the anode and cathode, respectively, and a voltage waveform having a hierarchical structure as described herein is applied between these electrodes. With a small time delay (e.g., less than about 5 milliseconds), as a next step, electrodes 604 and 610 are selected as the anode and cathode, respectively, and the waveform is again applied between this set of electrodes. After a small time delay, as a next step, electrodes 605 and 611 are selected as the anode and cathode, respectively, for the next application of the voltage waveform. In a next step, after a small time delay, electrodes 606 and 612 are selected as the anode and cathode, respectively, for the application of the voltage waveform. In some embodiments, one or more of the waveforms applied between the electrode pairs are applied during a refractory period of the cardiac cycle, as described in more detail herein.

[0037] In some embodiments, the ablation pulse waveforms described herein are applied during the refractory period of the cardiac cycle to avoid disruption of the sinus rhythm of the heart. In some embodiments, a method of treatment includes electrically pacing the heart with a cardiac stimulation device to ensure pacing capture to establish periodicity and predictability of the cardiac cycle, and then defining a time window during the refractory period of the cardiac cycle during which one or more pulsed ablation waveforms are delivered. FIG. 7 illustrates an example in which both atrial and ventricular pacing is applied (e.g., by pacing leads or catheters located in the right atrium and right ventricle, respectively). With time represented on the horizontal axis, FIG. 7 illustrates a series of ECG waveforms 60 and 61 driven by the pacing signals, as well as a series of ventricular pacing signals such as 64 and 65 and a series of atrial pacing signals such as 62 and 63. As shown in FIG. 7 by the thick arrows, there is an atrial refractory time window 68 and a ventricular refractory time window 69 following the atrial pacing signal 62 and the ventricular pacing signal 64, respectively. As shown in FIG. 7, the duration T r A common refractory time window 66 may be defined for each of the pulse waveforms 64. In some embodiments, the electroporation ablation waveform(s) may be applied in this common refractory time window 66. The start of this refractory time window 68 is offset from the pacing signal 64 by a time offset 59 as shown in FIG. 7. The time offset 59 may be less than about 25 milliseconds in some embodiments. At the next heartbeat, a similarly defined refractory time window 67 is the next time window available for application of the ablation waveform(s). In this manner, the ablation waveform(s) may be applied to a series of heartbeats, with each beat falling within the common refractory time window. In one embodiment, a series of packets may be applied to a series of heartbeats for a given electrode set, with each packet of pulses as defined above in the hierarchy of pulse waveforms being applied to a heartbeat.

[0038] The timing sequence of electrode activation for a series of electrode sets is illustrated in Figure 8 according to an embodiment. Using an example scenario in which it is desired to apply hierarchical ablation waveforms to electrode set j (each electrode set typically including at least one anode and at least one cathode), some embodiments utilize cardiac pacing as described above, applying a packet of pulses (e.g., including one or more groups of pulses or one or more sets of pulses) first to electrode set 1, followed by only a small time delay t d (on the order of about 100 μs or less), followed by a packet of pulses applied to electrode set 2. Then, with another time delay, a packet of pulses is applied to electrode set j, such as electrode set 3. This sequence 632 of applying packets of pulses to all electrode sets j is delivered during a refractory time window of a single heartbeat (e.g., common refractory time window 66 or 67), and each application to an electrode set constitutes one packet for that electrode set. Consider the case of a monophasic hierarchical waveform. With reference to the example monophasic waveform shown in FIG. 3, the waveform has a series of monophasic pulses, each having a pulse width w, separated by a time interval of duration t1 between successive pulses, a number m1 of which are arranged to form a group of pulses. Furthermore, the waveform has a number m2 of such groups of pulses separated by a time interval of duration t2 between successive groups, thereby defining a packet. If this waveform is applied sequentially to electrode sets j as described herein, the following inequality can be written: j[m2(m1w+t1(m1-1)+t2(m2-1)]+t d (j-1) <T r (1) This inequality indicates that the pulse waveform parameters m1 and m2 must be such that the entire delivery of the ablation pulse falls within the refractory time window T r In some embodiments, the refractory time window T rcan be less than or equal to about 140 milliseconds. The time offset of the start of the refractory window with respect to the pacing signal can be less than about 10 milliseconds. d While x can be arbitrary, when implemented in a finite state machine such as a computer processor (for example), they are integers as measured in some suitable units (e.g., microseconds, nanoseconds, or a multiple of the time of the underlying processor clock). Given the number of electrode sets j, equation (1) represents a Diophantine inequality that mutually constrains the parameters of the pulse waveforms (pulse width, time interval, and number of pulses and groups) such that the total duration of waveform application for electrode set j is less than a given common refractory period. In some embodiments, a set of solutions to the Diophantine inequality can be found based on partial constraints on the parameters of the pulse waveforms. For example, the generator may determine the pulse waveform parameters and / or some of the related parameters, such as the pulse width w and the time delay t d may require input of j, and then the system console will determine the rest of the pulse waveform parameters. In this case, the number of electrode sets j is also an input to the system that constrains the solution determination. In one embodiment, the system console may show a set of more than one possible solutions for such waveform parameters for the user to select, while in alternative embodiments, the system automatically selects or determines the waveform parameters. In some embodiments, the solutions may be calculated and directly satisfied in a predetermined form, for example, at the system console of the pulse generator. For example, all of the pulse waveform parameters are predetermined to satisfy a Diophantine inequality similar to equation (1), and the waveform is preprogrammed in the system. Perhaps the predetermined solution(s) may depend on the number of electrode sets j, or alternatively the solution(s) may be predetermined assuming a maximum number of electrode sets. In some embodiments, more than one solution may be predetermined and made available for user selection at the system console.

[0039] While the Diophantine inequality (1) reserves the delivery of a single waveform packet for a single refractory time window, a complete waveform may involve multiple packets. The number of packets may be predetermined, and in one embodiment, may range from 1 to 28 packets, including all values ​​and subranges therebetween. A suitable refractory time window T r can be predetermined and / or in one embodiment can be predefined, or in alternative embodiments, it can be selected by a user from within a certain predefined range. While inequality (1) has been expressly stated for waveforms of a monophasic hierarchy, similar inequalities may be stated for biphasic waveforms, or for waveforms combining monophasic and biphasic elements.

[0040] A schematic diagram of the delivery of an ablation waveform to multiple electrode sets j by a sequence of packets at the top waveform hierarchy is provided in FIG. 8. A first waveform packet 632 is delivered to the sequence of electrodes j in succession for the entire sequence of electrodes, where the waveform parameters of this sequence satisfy a Diophantine inequality such as equation (1). This entire sequence of voltage waveforms is delivered within a defined refractory time window of a single paced heartbeat. After a packet delay t3 equal to one pacing period, the next waveform packet 633 is delivered to electrode set j in succession for the entire sequence of electrodes with the same waveform parameters. Waveform delivery continues for a predetermined number of packets until the last waveform packet 636 is delivered to electrode set j in succession. Thus, ablation delivery occurs for as many paced heartbeats as there are packets. The voltage amplitude for the waveform can range from about 700 V to about 10,000 V, more preferably from about 1,000 V to about 8,000 V, including all values ​​and subranges therebetween, as suitable and convenient for clinical applications.

[0041] In some embodiments, the complete ordering of electrode sets can be further divided into smaller partial orderings of electrode sets / electrode subsets. For example, the complete ordering of electrode set j can be divided into electrode set j1 in a first partial ordering / first subset, electrode set j2 in a second partial ordering / second subset, etc., into N partial orderings. N The waveform packets are first applied to the first partial sequence of electrode set j1, then to the second partial sequence of electrode set j2, etc., with cardiac pacing employed throughout, and with the waveform packets all applied within the appropriate refractory time window.

[0042] 9 is a schematic diagram of a system architecture for an ablation system 200 configured for delivery of a pulsed voltage waveform. The system 200 includes a system console 215 that in turn includes a pulsed waveform generator and controller 202, a user interface 203, and a switch 205 for isolating a connection box 210 (to which multiple catheters may be connected) from the voltage pulses delivered by the generator. In some embodiments, the generator / controller 202 can include a processor, which can be any suitable processing device configured to execute and / or perform a set of instructions or code. The processor can be, for example, a general purpose processor, a field programmable gate array (FPGA), an application specific integrated circuit (ASIC), a digital signal processor (DSP), and / or the like. The processor can be configured to execute and / or perform application processes and / or functions associated with other modules, processes and / or functions associated with the system and / or its associated networks (not shown).

[0043] In some embodiments, system 200 can also include a memory and / or database (not shown) configured to store, for example, pacing data, waveform information, and / or the like. The memory and / or database can independently be, for example, a random access memory (RAM), a memory buffer, a hard disk, a database, an erasable programmable read-only memory (EPROM), an electrically erasable read-only memory (EEPROM), a read-only memory (ROM), a flash memory, and / or the like. The memory and / or database can store instructions that cause generator / controller 202 to perform modules, processes, and / or functions associated with system 200, such as, for example, generating pulsed waveforms and / or cardiac pacing.

[0044] System 200 may communicate with other devices (not shown) via one or more networks, each of which may be any type of network, such as, for example, a local area network (LAN), a wide area network (WAN), an optical network, a telecommunications network, and / or the Internet, implemented as a wired and / or wireless network. Any or all of the communications may be secured (e.g., encrypted) or unsecured, as known in the art. System 200 may include and / or encompass personal computers, servers, workstations, tablets, mobile devices, cloud computing environments, applications or modules executing on these platforms, and / or the like.

[0045] The system console 215 delivers ablation pulses to an ablation catheter 209 that is suitably positioned in the patient's anatomy, for example, a loop around the patient's pulmonary veins in the pericardial space of the patient's heart. The intracardiac ECG recording and pacing catheter 212 is connected to an ECG recording system 208 via a connection box 210. The ECG recording system 208 is connected to a cardiac stimulator or pacing unit 207. The cardiac stimulator 207 can send a pacing output to the recording and pacing catheter 212. In general, both atrial and ventricular pacing signals can be generated as output from the cardiac stimulator 207, and in some embodiments there can be separate intracardiac atrial and ventricular pacing catheters (not shown) or leads, each of which can then be positioned and / or located in the appropriate ventricle. The same pacing output signal is also sent to the ablation system console 215. The pacing signal may be received by the ablation system console, and based on the pacing signal, an ablation waveform may be generated by the generator / controller 202 within a common refractory window as described herein. In some embodiments, the common refractory window may begin substantially immediately (or after a very small delay) after the ventricular pacing signal and may continue thereafter for a duration of approximately 130 ms or less, in which case an entire packet of the ablation waveform is delivered within this duration as previously described.

[0046] The user interface 203 associated with the ablation system console 215 can be implemented in various forms as convenient for application. When an epicardial ablation catheter is delivered via a subxiphoid approach and placed on the epicardium beside the pulmonary veins as shown in FIG. 1, it may be fastened in place at ends 8 and 9 by passing the ends through the scintigraphy tool. Depending on the size of the particular left atrial anatomy, a subset of the electrodes may be placed in a surrounding manner beside the pulmonary veins, while the remainder of the electrodes may be retracted into the scintigraphy tool (not shown in FIG. 1) and thus not exposed. In such an embodiment, the surrounding / exposed electrodes may be selectively used to deliver ablation energy. An embodiment of a user interface suitable for use with an ablation catheter is depicted diagrammatically in FIG. 10. In FIG. 10, the user selects the number of proximal electrodes in the scintigraphy tool and the number of distal electrodes in the scintigraphy tool, as shown in windows 653 and 654, respectively, where the user makes selections 650 and 651, respectively, for each number of electrodes. The complementary electrodes / subset of electrodes on the catheter not in the scintillation tool (derived from the complete set of catheter electrodes) are the exposed electrodes used in the delivery of the pulsed electric field for electroporation ablation. The magnitude of the delivered waveform is controlled by an input mechanism, such as, for example, a slider 658 that can be moved over a predefined voltage range, indicated by 657 in FIG. 10. Once the voltage amplitude is selected, an initialize (or initialize) button 655 provided in the user interface is engaged to prepare the ablation system for energy delivery. In one example, this can take the form of a trigger that charges a capacitor bank to store energy for subsequent delivery to the catheter.

[0047] As shown in FIG. 11, the initialize button 660 can also act as a status indicator to indicate that the initialization process is in progress. The status can be indicated by text (such as "Initializing..." as shown in FIG. 11, and / or a color such as yellow to indicate that initialization has not yet started or is still in progress). Once the initialization is complete (e.g., the capacitor bank is fully or sufficiently charged), the same button 663 now indicates the completion of the process ("Initialized") as shown in FIG. 12, and in some embodiments as described, it can change color (e.g., changing from yellow to green) and / or shape to further indicate the completion of initialization. Meanwhile, the ablation system waits for receipt of a pacing signal from the cardiac stimulation device or pacing unit. Once a pacing signal is detected and / or confirmed along with the completion of the initialization process, a second button 665 becomes available for the user to engage in confirmation of pacing capture. If no pacing signal is detected by the ablation system console, then the second button 665 is not enabled. To confirm pacing capture, the user can monitor an ECG display (not shown) and view the cardiac stimulator pacing output in conjunction with the intracardiac ECG recording (which confirms that atrial and ventricular contractions are actually driven by the pacing signal to define a predictable common refractory window). Once the user has visually confirmed pacing capture from the ECG data, the user can then confirm pacing capture at the ablation system using the "Confirm Pacing Capture" button 665.

[0048] As shown in FIG. 13, once pacing capture is confirmed in the ablation system, the system becomes available for ablation or pulsed electric field delivery. The pacing capture confirmation button changes state 670 (which can change in color, shape, and / or otherwise) to indicate readiness for ablation delivery as indicated by 670. Additionally, the ablation delivery button 675 becomes available to the user. The user can use the ablation delivery button 675 to deliver ablation synchronously with the paced cardiac rhythm. In some embodiments, the user uses the button 675 for the duration of ablation delivery, at which point the button changes shape or color to indicate completion of ablation delivery. In some embodiments, if the user releases the button 675 before ablation delivery is complete, ablation delivery immediately stops with a very small time lag, for example, 20 ms or less. In some embodiments, if the user does not use the ablation button 675 after it is displayed as available, it remains available only for a limited duration before it is disabled as a safety mechanism. In some embodiments, the ablation button 675 can be a software or graphic button on a user interface display, while in other embodiments it can be a mechanical button whose response depends on an activated or available state determined by the system, and in other embodiments, the button 675 can be in the form of any of a variety of control input devices, such as, without limitation, a lever, a joystick, a computer mouse, etc. In one embodiment, the ablation system can have a separate emergency stop button for added safety, for example, if it is desired to immediately stop operation of the system. In one embodiment, the ablation console can be mounted on a rotating dolly or wheeled cart, and the user can control the system using a touch panel interface in the sterile field.The touch panel can be, for example, an LCD touch panel in a plastic housing that can be mounted on a standard medical rail or post, and the touch panel can have, at a minimum, the functionality described above. The interface can be covered, for example, with a clear, sterile plastic drape.

[0049] The waveform parameters as detailed herein may be determined by the design of the signal generator, and in some embodiments, the parameters may be predetermined. In some embodiments, at least a subset of the waveform parameters may be determined by user control, as may be advantageous for a given clinical application. The specific examples and descriptions herein are exemplary in nature, and those skilled in the art may make modifications based on the teachings herein without departing from the scope of the embodiments disclosed herein.

[0050] One or more embodiments described herein relate to a computer storage product with a non-transitory computer-readable medium (which may also be referred to as a non-transitory processor-readable medium) having thereon instructions or computer code for performing various computer-implemented operations. The computer-readable medium (or processor-readable medium) is non-transitory in the sense that it does not include a transitory transmission signal itself (e.g., a transmitted electromagnetic wave carrying information in a transmission medium such as space or a cable). The medium and computer code (which may also be referred to as code or algorithms) may be designed and constructed for a specific purpose(s). Examples of non-transitory computer-readable media include, but are not limited to, magnetic storage media such as hard disks, floppy disks, magnetic tapes; optical storage media such as compact disks / digital video disks (CD / DVD), compact disk read only memory (CD-ROM), and holographic devices; magneto-optical storage media such as optical disks; carrier wave signal processing modules; and hardware devices that are specifically configured to store and execute program code such as application specific integrated circuits (ASICs), programmable logic devices (PLDs), read only memory (ROM), and random access memory (RAM) devices. Other embodiments described herein relate to computer program products that may include, for example, instructions and / or computer code disclosed herein.

[0051] One or more of the embodiments and / or methods described herein may be implemented by software (executed on hardware), hardware, or a combination thereof. Hardware modules may include, for example, general purpose processors (or microprocessors or microcontrollers), field programmable gate arrays (FPGAs), and / or application specific integrated circuits (ASICs). Software modules (executed on hardware) may be expressed in a variety of software languages ​​(e.g., computer code), including C, C++, Java, Ruby, Visual Basic, and / or other object-oriented, procedural, or other programming languages ​​and development tools. Examples of computer code include, but are not limited to, microcode or microinstructions such as those produced by a compiler, machine instructions, code used to create web services, and files containing high-level instructions that are executed by a computer using an interpreter. Additional examples of computer code include, but are not limited to, control signals, encryption code, and compression code.

[0052] While various embodiments have been described above, it should be understood that they are presented for purposes of illustration and not limitation. Where the methods described above show certain events occurring in a particular order, the ordering of the certain events can be altered. Furthermore, certain events may be performed simultaneously in parallel processes, where possible, as well as in the order described above.

Claims

1. 1. A system comprising: A pulse waveform generator; an ablation device coupled to the pulse waveform generator, the ablation device including at least one electrode configured to deliver an ablation pulse to tissue, in use; the pulse waveform generator is configured to deliver voltage pulses to the ablation device in the form of a pulsed waveform; (a) a first level hierarchy of the pulsed waveform includes a first set of pulses, each pulse having a pulse duration and a first time interval separating successive pulses; (b) the second level hierarchy of the pulsed waveform includes a plurality of the first sets of pulses as a second set of pulses, a second time interval separating successive first sets of pulses, the second time interval being at least three times the duration of the first time interval; (c) the system, wherein a third level hierarchy of the pulsed waveform includes a plurality of second sets of pulses as a third set of pulses, a third time interval separating consecutive second sets of pulses, the third time interval being at least 30 times the duration of the second level time interval.

2. 2. The system of claim 1, wherein the pulses of each first set of pulses include monophasic pulses having a voltage amplitude of at least 800 volts, and wherein the pulse duration of each monophasic pulse is in a range from about 1 microsecond to about 300 microseconds.

3. The system of claim 1 , wherein each second set of pulses includes at least two first sets of pulses and fewer than 40 first sets of pulses.

4. The system of claim 1 , wherein each third set of pulses includes at least 2 second sets of pulses and less than 30 second sets of pulses.

5. 2. The system of claim 1, wherein the pulses of each first set of pulses each comprise biphasic pulses having a voltage amplitude of at least 800 volts, and wherein the pulse duration of each biphasic pulse ranges from about 0.5 nanoseconds to about 20 microseconds.

6. The system of claim 1 , wherein the second time interval is at least 10 times the duration of the pulse.

7. The system of claim 1 , wherein the ablation device comprises an ablation catheter configured for epicardial placement.

8. The system of claim 1 , wherein the ablation device comprises an ablation catheter configured for endocardial placement.

9. 1. A system comprising: A pulse waveform generator; an ablation device coupled to the pulse waveform generator, the ablation device including at least one electrode configured to deliver an ablation pulse to tissue, in use; the pulse waveform generator is configured to deliver voltage pulses in the form of a pulsed waveform to the ablation device; (a) a first level hierarchy of the pulsed waveform includes a first set of pulses, each pulse having a pulse duration and a first time interval separating successive pulses; (b) the second level hierarchy of the pulsed waveform includes a plurality of the first sets of pulses as a second set of pulses, a second time interval separating successive first sets of pulses, the second time interval being at least three times the duration of the first time interval; (c) the third level hierarchy of pulsed waveforms includes a plurality of second sets of pulses as a third set of pulses, a third time interval separating successive second sets of pulses, the third time interval being at least 30 times the duration of the second level time interval; The system, wherein the pulse waveform generator is configured to apply a plurality of the third sets of pulses to the ablation device with a time delay of at most about 5 milliseconds between successive third sets of pulses.

10. The system of claim 9 , wherein the ablation device comprises an ablation catheter configured for epicardial placement.

11. The system of claim 9 , wherein the ablation catheter comprises at least four electrodes.

12. 10. The system of claim 9, wherein each second set of pulses includes at least two first sets of pulses and fewer than 40 first sets of pulses.

13. 10. The system of claim 9, wherein each third set of pulses includes at least 2 second sets of pulses and less than 30 second sets of pulses.

14. 10. The system of claim 9, wherein the pulses of each first set of pulses have a voltage amplitude of at least 800 volts.

15. 1. A system comprising: A pulse waveform generator; an ablation device coupled to the pulse waveform generator, the pulse waveform generator including at least one electrode configured, in use, to deliver an ablation pulse to tissue; a cardiac stimulator coupled to the pulse waveform generator, the cardiac stimulator configured, in use, to generate a pacing signal for cardiac stimulation; the pulse waveform generator configured to deliver voltage pulses in the form of a pulsed waveform to the ablation device in synchronization with the pacing signal; (a) a first level hierarchy of the pulsed waveform includes a first set of pulses, each pulse having a pulse duration and a first time interval separating successive pulses; (b) the second level hierarchy of the pulsed waveform includes a plurality of the first sets of pulses as a second set of pulses, with a second time interval separating successive first sets of pulses; (c) the third level hierarchy of pulsed waveforms includes a plurality of second sets of pulses as a third set of pulses, a third time interval separating successive second sets of pulses; the pulse waveform generator is configured to apply a plurality of the third sets of pulses to a predetermined number of electrode sets of the ablation device with a time delay between successive third sets of pulses; the system, wherein the pulse waveform generator is configured to generate the pulsed waveform, and wherein each of the first set of pulses and each of the second set of pulses, the predetermined number of electrode sets, the time delays, the pulse durations, the first time intervals, the second time intervals, and the third time intervals are jointly constrained by a Diophantine inequality.

16. The system of claim 15 , wherein the Diophantine inequality constraints are further characterized by a refractory time window.

17. The system of claim 15 , wherein the number of the first sets of pulses and the number of the second sets of pulses are predetermined.

18. 16. The system of claim 15, wherein the pulsed waveform generator is further configured to deliver the pulsed waveform spaced from the pacing signal by a time offset, the time offset being less than about 25 milliseconds.

19. 16. The system of claim 15, wherein the third time interval corresponds to a pacing period associated with the pacing signal.

20. 16. The system of claim 15, wherein the second time interval is at least three times the duration of the first time interval.

21. 16. The system of claim 15, wherein the third time interval is at least 30 times the duration of the second time interval.

22. 16. The system of claim 15, wherein the second time interval is at least 10 times the duration of the pulse.

23. The system of claim 15 , wherein the ablation device comprises an ablation catheter configured for epicardial placement.

24. The system of claim 15 , wherein the ablation device comprises an ablation catheter configured for endocardial placement.

25. 1. A system comprising: a pulse waveform generator including a user interface; an ablation device coupled to the pulse waveform generator, the ablation device including a plurality of electrodes configured, in use, to deliver ablation pulses to tissue of a patient; a cardiac stimulator coupled to the pulse waveform generator, the cardiac stimulator configured, in use, to generate a pacing signal for cardiac stimulation of the patient; the pulse waveform generator is configured to deliver voltage pulses to the ablation device in the form of a pulsed voltage waveform having at least three levels of hierarchy; the pulse waveform generator is further configured to deliver the pulsed voltage waveform synchronously with the pacing signal; the user interface of the pulse waveform generator configured to receive an indication of user confirmation of capture of the pacing signal by the patient's heart; The system, wherein the pulse waveform generator is configured to deliver the pulsed voltage waveform upon receipt of the indication of user confirmation.

26. (a) a first level hierarchy of the pulsed waveform includes a first set of pulses, each pulse having a pulse duration, a first time interval separating successive pulses; (b) a second level hierarchy of the pulsed waveform includes a plurality of the first sets of pulses as a second set of pulses, a second time interval separating successive first sets of pulses; (c) the third level hierarchy of the pulsed waveform includes a plurality of second sets of pulses as a third set of pulses, a third time interval separating successive second sets of pulses; the pulse waveform generator is further configured to apply a plurality of third sets of pulses to a predetermined number of electrode sets of the ablation device with a time delay between successive third sets of pulses; 26. The system of claim 25, wherein each of the first set of pulses and each of the second set of pulses, the predetermined number of electrode sets, the time delays, the pulse durations, the first time intervals, the second time intervals, and the third time intervals are jointly constrained by a Diophantine inequality.

27. 26. The system of claim 25, wherein the pulsed waveform generator is configured to deliver the pulsed waveform only after a predetermined time interval after the indication of user confirmation.

28. 30. The system of claim 27, wherein the user interface includes a control input device, and the pulse waveform generator is configured to deliver the pulsed waveform upon user engagement of the control input device.

29. 30. The system of claim 28, wherein the pulsed waveform generator is configured to cease delivery of a pulsed waveform within 20 milliseconds of user withdrawal from the control input device.

30. 1. A method comprising generating a pulsed waveform and delivering the pulsed waveform to an ablation device, the pulsed waveform comprising: (a) a first level hierarchy of the pulsed waveforms including a first set of pulses, each pulse having a pulse duration and a first time interval separating successive pulses; (b) a second level hierarchy of the pulsed waveforms including a plurality of the first sets of pulses as a second set of pulses, a second time interval separating successive first sets of pulses, the second time interval being at least three times the duration of the first time interval; (c) a third level hierarchy of the pulsed waveforms including a plurality of second sets of pulses as a third set of pulses, a third time interval separating successive second sets of pulses, the third time interval being at least 30 times the duration of the second level time interval; The method comprising:

31. 1. A method comprising: generating a pulsed waveform; generating a pacing signal by a cardiac stimulator; delivering the pulsed waveform to an ablation device synchronously with the pacing signal; The pulsed waveform is (a) a first level hierarchy of the pulsed waveforms including a first set of pulses, each pulse having a pulse duration and a first time interval separating successive pulses; (b) a second level hierarchy of the pulsed waveforms including a plurality of the first sets of pulses as a second set of pulses, a second time interval separating successive first sets of pulses, the second time interval being at least three times the duration of the first time interval; (c) a third level hierarchy of the pulsed waveforms including a plurality of second sets of pulses as a third set of pulses, a third time interval separating successive second sets of pulses, the third time interval being at least 30 times the duration of the second level time interval; The method comprising:

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