Multipolar simultaneous pulmonary artery radiofrequency ablation catheter

Abstract

A device is provided that can be used to treat pulmonary hypertension by pulmonary denervation. [Solution] A multipolar simultaneous pulmonary artery radiofrequency ablation catheter, comprising: an adjustment device disposed on a control handle; a cavity disposed within the catheter body; lead wires, a temperature sensing wire, and a pull wire disposed within the cavity; one end of the catheter body is flexible and connected to an annular ring; the tension of the pull wire is adjusted via the adjustment device to achieve radian control of the flexible end; a shape memory wire is disposed within the annular ring, one end extending to the tip of the annular ring, and the other end passing through the base of the annular ring and fixed to the flexible end of the catheter body; the annular ring has a group of electrodes, each connected to a lead wire and a temperature sensing wire; the lead wires and temperature sensing wire pass through the catheter body and are electrically connected to the control handle.

Description

[Technical field]

[0001] The present invention relates to medical devices for treating pulmonary hypertension in the pulmonary arteries by a de-sympathetic technique, for example using a multipolar simultaneous pulmonary artery radiofrequency ablation catheter, and to methods for diagnosing and treating pulmonary hypertension. [Background technology]

[0002] Pulmonary hypertension (PH) is understood to be an intractable disease affecting the cardiovascular, respiratory, connective tissue, immune, and rheumatic systems. Currently available clinical treatments for pulmonary hypertension are limited and have low therapeutic efficacy. Although the incidence of primary pulmonary hypertension is low, secondary pulmonary hypertension associated with pulmonary interstitial fibrosis, connective tissue disease, portal hypertension, chronic pulmonary embolism, and left heart failure is common, with a 5-year mortality rate of up to 30%. Therefore, prevention and treatment of pulmonary hypertension are of great significance.

[0003] In recent years, new drugs targeting pulmonary hypertension have emerged based on the study of its pathogenesis, but some of these drugs have significant limitations, including numerous side effects, inappropriate dosage forms, high costs, and unreliable efficacy, preventing many of them from being widely applied in clinical treatment. Summary of the Invention [Problem to be solved by the invention]

[0004] At least one aspect of the invention disclosed herein involves the understanding, supported by experimental data demonstrating this, that pulmonary hypertension is associated with excessive sympathetic nerve activity and hyperactive receptors in the pulmonary arteries. Blocking the sympathetic nerves or permanently damaging the receptor structure and function can reduce pulmonary artery pressure, making treatment more likely to be successful.

[0005] Some embodiments disclosed herein provide a multipolar simultaneous pulmonary artery radiofrequency ablation catheter for treating pulmonary hypertension in the pulmonary artery by desympathetic nerve denervation. In some embodiments, the catheter only heats adherent tissue and not blood. Furthermore, in some embodiments, the catheter can be configured to provide cold saline perfusion at or near the ablation site to protect the vascular intima. Some embodiments also provide the advantages of simple operation, short operation time, and controllable and precise ablation.

[0006] In some embodiments, a multipolar simultaneous pulmonary artery radiofrequency ablation catheter may include a control handle, a catheter body, and an annular ring. The control handle may include an adjustment device. The catheter body may be hollow and may include a cavity. One or more lead wires, one or more temperature sensing wires, and one or more pull wires may be disposed within the cavity. One end of the catheter body may be flexible. The flexible end may be connected to the annular ring, and the other end of the catheter body may be connected to the control handle. One end of the pull wire may be connected to the flexible end, and the other end of the pull wire may be connected to the adjustment device. The tension of the pull wire may be adjusted via the adjustment device to achieve shape control, e.g., curvature control, of the flexible end. A shape memory wire may be disposed within the annular ring. One end of the shape memory wire may extend to the tip of the annular ring, and the other end of the shape memory wire may pass through the base of the annular ring and be fixed to the flexible end of the catheter body. The annular ring can include a population of electrodes, each connected to one or more lead wires and one or more temperature sensing wires, the lead wire(s) and temperature sensing wire(s) extending through the catheter body and electrically connected to the control handle.

[0007] An infusion tube may be placed within the cavity of the catheter body and a through hole may be placed over one or more electrodes. The infusion tube may be connected to the electrodes through the annular ring. Infused fluid may flow out of the through hole and thus be used for cooling purposes during ablation as part of a percutaneous pulmonary denervation (PADN) procedure.

[0008] The electrodes on the annular ring may be made from a material selected from the group consisting of platinum-iridium alloy, gold, stainless steel, and nickel alloy, with the number of electrodes ranging from 3 to 30, the electrode diameter ranging from 1.3 to 2.0 mm, the electrode length ranging from 1.2 to 4 mm, and the space between adjacent electrodes end to end ranging from 0.5 to 10 mm.

[0009] The flexible end of the catheter body can include a countersink, the inner diameter of which can match the outer diameter of the root of the annular ring so that the root of the annular ring can be inserted and secured within the countersink.

[0010] The flexible end of the catheter body includes a groove with a connector disposed within the groove, one end of the connector being connected to a pull wire and the other end of the connector being connected to a shape memory wire.

[0011] The material of the shape memory wire in the annular ring may be a shape memory alloy selected from the group consisting of nickel-titanium alloy, stainless steel, or titanium, having a diameter of 0.25-0.5 mm. The diameter of the annular ring may be 12-40 mm. For example, the annular ring may be configured, for example, using a shape memory material, to deform into a circumferential shape having a desired diameter (e.g., in the range of 12-40 mm) when energized. Preferably, 10 electrodes are disposed on the annular ring. The width of the bare portions of the electrodes is 0.75 mm, with a space between them of 5 mm.

[0012] The flexible end may be made of a medical grade polymeric material with a length ranging from 30 to 80 mm. The connection may be achieved by a UV curable adhesive. The joint between the flexible end and the annular ring may be sealed.

[0013] The pull wire is made from stainless steel or a nickel-titanium alloy. The outside of the pull wire comprises a spring coil, and the outside of the spring coil comprises a spring sleeve made from a polyimide material.

[0014] In some embodiments, the catheters may be packaged in a kit that includes a number of different annular rings that are biased to have different diameters. In some embodiments where the annular ring, flexible body, and handle are permanently connected to one another, the kit may include a number of different catheters, each having a handle, flexible body, and annular rings of different sizes.

[0015] In some embodiments and / or methods of use, the catheter can heat tissue directly in contact with the electrodes with radio frequency energy and avoid heating the blood. Furthermore, the catheter can provide the advantages of easy operation, short operation time, and controllable and precise ablation. The catheter body can be made of a polymeric material that is preferably a poor thermal conductor, so that when heating the electrodes, heat transfer to the blood flowing in contact with the catheter body can be avoided, thereby effectively avoiding heating the blood.

[0016] Furthermore, the shape or curvature of the flexible end can be adjusted by operating the adjustment device, which allows an operator to control the handle with one hand, so that the curvature of the flexible end can be easily adjusted for the purpose of positioning the annular ring and the electrode. Thus, after being positioned as desired, the electrode on the annular ring can be pressed against the pulmonary artery to achieve ablation of the pulmonary artery intima. During application of the high frequency current, the electrode can produce a high local temperature and cause severe damage on the vascular intima.

[0017] Thus, in some embodiments, the catheter may be configured to provide cold saline perfusion to reduce local temperature. When the electrodes receive an electric current, saline is automatically and uniformly diffused through the through-holes. This can provide beneficial cooling, for example, reducing the local temperature to below 60° C. to protect the vascular intima.

[0018] In some embodiments, a multipolar simultaneous pulmonary artery radiofrequency ablation catheter may include a control handle, a catheter body, and an annular ring. The control handle may include an adjustment device. The catheter body may be hollow and may include a cavity disposed within the catheter body. The lead wires, temperature sensing wires, and pull wires may be disposed within the cavity. One end of the catheter body may be flexible, and the flexible end of the catheter body may be connected to the annular ring. The other end of the catheter body may be connected to the control handle. One end of the pull wire may be connected to the flexible end. The other end of the pull wire may be connected to an adjustment device on the control handle. The adjustment device may adjust the tension of the pull wire to change the curvature of the flexible end. A shape memory wire may be disposed within the annular ring. One end of the shape memory wire may extend to the tip of the annular ring, and the other end of the shape memory wire may pass through the base of the annular ring and be fixed to the flexible end of the catheter body. The annular ring may include electrodes. The group of electrodes may include a first electrode having a first length, a second electrode having a second length different from the first length, and a third electrode. Each electrode of the group of electrodes may be connected to a lead wire and a temperature sensing wire. The lead wire and the temperature sensing wire may pass through the catheter body and be electrically connected to the control handle.

[0019] The annular ring may extend from a root of the annular ring to a tip of the annular ring and include a curve of less than 360 degrees. The annular ring may extend from a root of the annular ring to a tip of the annular ring and include a curve of more than 270 degrees. The annular ring may include a first diameter and a second diameter different from the first diameter. The first diameter may be at least 25 mm and the second diameter may be at least 20 mm.

[0020] The electrodes of the electrode group may be substantially coplanar. The first electrode may have a first length of at least 4 mm. The second electrode may have a second length of at least 3 mm. The third electrode may have a third length different from the first length and different from the second length. The third length may be at least 2 mm.

[0021] In some embodiments, the catheter may include a catheter body and an annular ring. One end of the catheter body may be flexible and may be connected to the annular ring. The curve of the annular ring may be less than 360 degrees and greater than 270 degrees.

[0022] The annular ring may comprise an electrode group including a first electrode having a first length, a second electrode having a second length different from the first length, and a third electrode having a third length different from the first length and different from the second length. The electrodes of the electrode group may be substantially coplanar and may be arranged along a curve of the annular ring extending from a root of the annular ring to a tip of the annular ring. The first length may be at least 4 mm. The second length may be at least 3 mm and may be less than the first length. The third length may be at least 2 mm and may be less than the second length. The first length may be 4 mm. The electrode group may comprise less than four electrodes.

[0023] The first electrode may be spaced an equal distance from the second and third electrodes. The equal distance may be 1 mm. The first electrode may be a greater distance from the root of the annular ring than the second and third electrodes.

[0024] In some embodiments, the controller may comprise a housing, an electronic display, a battery, an electronic data storage, and a computing device. The housing may comprise a catheter connection port disposed along a surface of the housing. The connection port may be configured to interface with a catheter. The catheter may comprise a first electrode having a first length and a second electrode having a second length different from the first length. The housing may comprise an electronic display disposed along a surface of the housing. The housing may cover the battery, the electronic data storage, and the computing device. The electronic display may be configured to present a user interface. The battery may be configured to store a sufficient level of power for ablation using the first electrode or a sufficient level of power for ablation using the second electrode. The electronic data storage may comprise stored patient profiles characterizing a plurality of patients. The computing device may comprise one or more processors. The computing device may be in communication with the electronic data storage, the electronic display, and the battery. The computing device may be configured to at least accept a selection of a first patient profile from the user interface of the stored patient profiles, display information characterizing the first patient profile on the user interface, accept a selection of a first electrode from the user interface and direct a sufficient level of power from the battery to the first electrode for ablation using the first electrode, and accept a selection of a second electrode from the user interface and direct a sufficient level of power from the battery to the second electrode for ablation using the second electrode.

[0025] The computing device may be configured to simultaneously direct power from the battery to the first electrode and direct power from the battery to the second electrode. The computing device may be configured to direct power from the battery to the first electrode and direct power from the battery to the second electrode at different times. The computing device may be configured to interrupt power directed from the battery to the first electrode and direct power from the battery to the second electrode after power directed from the battery to the first electrode is interrupted. The computing device may be configured to direct power from the battery to the first electrode after the battery has finished charging. The computing device may be configured to display first electrode ablation information acquired by the first sensor on a user interface while the first electrode is receiving power from the battery. The computing device may be configured to store the first electrode ablation information with the first patient profile. The computing device may be configured to display first electrode ablation information obtained by the first sensor on the user interface while the first electrode is receiving power from the battery and to display second electrode ablation information obtained by the second sensor on the user interface while the second electrode is receiving power from the battery. The second electrode ablation information may be displayed on the user interface after the first electrode stops receiving power from the battery.

[0026] The housing may include a power connection port configured to receive a level of power sufficient to charge the battery.

[0027] The catheter may include a first sensor connected to the first electrode. The catheter may include a first sensor connected to the first electrode and a second sensor connected to the second electrode.

[0028] In some embodiments, a computer-implemented method may include accepting a selection of a first patient profile of a plurality of stored patient profiles from a user interface presented on an electronic display disposed on a surface of the housing under control of one or more computing devices executing certain computer-executable instructions. The method may include displaying information characterizing the first patient profile on the user interface. The method may include accepting a selection of a first electrode from the user interface. The method may include directing a level of power sufficient for ablation using the first electrode to the first electrode from a battery configured to store a sufficient level of power for ablation using the first electrode. The method may include accepting a selection of a second electrode from the user interface. The method may include directing a level of power sufficient for ablation using the second electrode from the battery to the second electrode. The battery may be configured to store a sufficient level of power for ablation using the second electrode. The housing may include a catheter connection port disposed along a surface of the housing. The connection port may be configured to interface with a catheter comprising a first electrode having a first length and a second electrode having a second length different from the first length. The housing may encase a battery, an electronic data storage, and one or more computing devices that execute certain computer-executable instructions. The electronic data storage may comprise a plurality of stored patient profiles characterizing a plurality of patients.

[0029] The first electrode and the second electrode may be configured to convert power from the battery into radio frequency (RF) energy for ablation of sympathetic nerve fibers. The first electrode and the second electrode may be configured to convert power from the battery into ultrasonic energy for ablation of sympathetic nerve fibers. The first electrode and the second electrode may be configured to convert power from the battery into electroporation energy for ablation of sympathetic nerve fibers. The first electrode and the second electrode may be configured to convert power from the battery into ionization energy for ablation of sympathetic nerve fibers.

[0030] In some embodiments, a computer-readable non-transitory storage medium storing computer-executable instructions, the computer-executable instructions being configured, when executed by one or more computer systems, to cause the one or more computer systems to perform operations including accepting a selection of a first patient profile of a plurality of stored patient profiles from a user interface presented on an electronic display disposed on a surface of the housing. The operations may include displaying information characterizing the first patient profile on the user interface. The operations may include accepting a selection of a first electrode from the user interface. The operations may include directing a sufficient level of power from the battery to the first electrode for ablation using the first electrode. The battery may be configured to store a sufficient level of power for ablation using the first electrode. The operations may include accepting a selection of a second electrode from the user interface. The operations may include directing a sufficient level of power from the battery to the second electrode for ablation using the second electrode. The battery may be configured to store a sufficient level of power for ablation using the second electrode.

[0031] The housing may include a catheter connection port disposed along a surface of the housing. The connection port may be configured to interface with a catheter comprising a first electrode having a first length and a second electrode having a second length different from the first length. The housing may encase a battery, an electronic data storage, and one or more computer systems. The electronic data storage may include a plurality of stored patient profiles characterizing a plurality of patients.

[0032] The act of directing power from the battery to the second electrode may be performed by switching power directed from the battery from the first electrode to the second electrode. The act of directing power from the battery to the second electrode may direct an amount of power from the battery that is greater than the amount of power directed from the battery to the first electrode.

[0033] In some embodiments, a multipolar simultaneous pulmonary artery radiofrequency ablation catheter includes a control handle, a catheter body, and an annular ring. The control handle may include an adjustment device. The catheter body may be hollow and may include a cavity disposed within the catheter body. One end of the catheter body may be flexible. The flexible end may be connected to the annular ring. The other end of the catheter body may be connected to the control handle. One end of a pull wire may be connected to the flexible end and the other end of the pull wire may be connected to an adjustment device on the control handle. The adjustment device may adjust the tension of the pull wire to change the curvature of the flexible end. A shape memory wire may be disposed within the annular ring. One end of the shape memory wire may extend to a tip of the annular ring and the other end of the shape memory wire may pass through a base of the annular ring and be fixed to the flexible end of the catheter body. The annular ring may be formed into an oval shape with a major axis and a minor axis. The major axis may include a first diameter along the major axis that is greater than a second diameter along the minor axis. The annular ring may extend from a root of the annular ring to a tip of the annular ring and may comprise a curve of less than 360 degrees. The annular ring may comprise an electrode disposed across the apex of the long axis.

[0034] In some embodiments, the catheter comprises a catheter body and an annular ring. One end of the catheter body may be flexible and may be connected to the annular ring. The annular ring may be ovoid.

[0035] The annular ring may have a major axis and a minor axis, the major axis having a first diameter along the major axis that is longer than a second diameter along the minor axis. The first diameter may be 5 mm longer than the second diameter. The major axis may be along a first axis of symmetry and the minor axis may be along a second axis of symmetry. The annular ring may include electrodes positioned across an apex of the major axis. The annular ring may be orthogonal to the end of the flexible catheter body. The annular ring may be planar. The annular ring may have a curve less than 360 degrees. The annular ring may have a curve less than 360 degrees and greater than 270 degrees.

[0036] The annular ring may comprise an electrode group including a first electrode having a first length, a second electrode having a second length different from the first length, and a third electrode having a third length different from the first length and different from the second length. The electrodes of the electrode group may be substantially coplanar. The first length may be at least 4 mm. The second length may be at least 3 mm and may be less than the first length. The third length may be at least 2 mm and may be less than the second length. The first length may be 4 mm. The first electrode may be spaced equal distances from the second electrode and the third electrode.

[0037] In some embodiments, a method of performing pulmonary denervation may include positioning an ablation device in the pulmonary trunk of a living animal. The pulmonary trunk may include a distal portion of the main pulmonary artery, a proximal portion of the left pulmonary artery, and a proximal portion of the right pulmonary artery. The method may include deploying an annular ring from the ablation device. The annular ring may have a long axis and a short axis. The long axis may have a first diameter along the long axis that is longer than a second diameter along the short axis. The method may include ablating at least one of the distal portion of the main pulmonary artery, the proximal portion of the left pulmonary artery, and the proximal portion of the right pulmonary artery.

[0038] In some embodiments, the controller may include a housing, an electronic display, an electronic data storage, and a computing device. The housing may include a connection port disposed along a surface of the housing. The connection port may be configured to interface with a catheter comprising a first electrode having a first length and a second electrode having a second length different from the first length. The electronic display may be disposed along a surface of the housing. The housing may cover the electronic data storage and the computing device. The electronic display may be configured to present a user interface. The electronic data storage may comprise stored patient profiles characterizing a plurality of patients. The computing device may comprise one or more processors. The computing device may be in communication with the electronic data storage and the electronic display. The computing device may be configured to at least accept a selection of a first patient profile from the user interface of the stored patient profiles, display information characterizing the first patient profile on the user interface, and direct a first power level to the first electrode sufficient for ablation using the first electrode. The first power level may be based on the first patient profile. The power may be directed from a power source. The power source may be a battery. The power source may be a power outlet connected to a power grid.

[0039] The catheter may include a second electrode having a second length different from the first length. The computing device may be configured to direct power to the second electrode at a second power level sufficient for ablation using the second electrode. The second power level may be based on a first patient profile. The second power level may be different from the first power level.

[0040] The housing may encase a battery. The battery may be configured to store power at a first power level sufficient for ablation using the first electrode. The computing device may be in communication with the battery and configured to direct power from the battery to the first electrode at a first power level sufficient for ablation using the first electrode. The housing may include a power connection port configured to receive a level of power sufficient to charge the battery. The computing device may be configured to direct power from the battery to the first electrode after the battery has finished charging. The computing device may be configured to direct power to the first electrode before the battery has finished charging.

[0041] The catheter may include a first sensor connected to the first electrode. The computing device may be further configured to display first electrode ablation information acquired by the first sensor on a user interface while the first electrode receives power from the battery. The computing device may be further configured to store the first electrode ablation information with the first patient profile. The first electrode ablation information may include a temperature. The catheter may include an annular ring formed in an oval shape with a major axis and a minor axis. The major axis may include a first diameter along the major axis that is longer than a second diameter along the minor axis. The first electrode may be positioned across an apex of the major axis.

[0042] In some embodiments, a computer-implemented method may be under the control of one or more computing devices executing certain computer-executable instructions. The method may include accepting a selection of a first patient profile, displaying information characterizing the first patient profile on a user interface, accepting the selection of the first patient profile from the user interface, determining a first power level from the first patient profile sufficient for ablation using a first electrode, and directing power at the first power level to the first electrode.

[0043] The first patient profile may be a portion of a plurality of stored patient profiles from a user interface presented on an electronic display disposed on a surface of the housing. The housing may include a catheter connection port disposed along a surface of the housing. The connection port may be configured to interface with a catheter comprising the first electrode. The housing may encase an electronic data store and one or more computing devices that execute certain computer-executable instructions. The electronic data store may include a plurality of stored patient profiles characterizing a plurality of patients.

[0044] The first electrode may be configured to convert the power into radio frequency (RF) energy for ablation of sympathetic nerve fibers. The first electrode may be configured to convert the power into ultrasonic energy for ablation of sympathetic nerve fibers. The first electrode may be configured to convert the power into electroporation energy for ablation of sympathetic nerve fibers. The first electrode may be configured to convert the power into ionization energy for ablation of sympathetic nerve fibers.

[0045] In some embodiments, a computer-readable non-transitory storage medium storing computer-executable instructions that, when executed by one or more computer systems, are configured to cause the one or more computer systems to perform the following operations: accept a selection of a first patient profile of a plurality of stored patient profiles from a user interface presented on an electronic display disposed on a surface of the housing; display information characterizing the first patient profile on the user interface; accept the selection of the first patient profile from the user interface; determine a first power level from the first patient profile sufficient for ablation using the first electrode; determine a second power level from the first patient profile sufficient for ablation using the second electrode; direct power at the first power level to the first electrode; and direct power at the second power level to the second electrode.

[0046] The housing may include a catheter connection port disposed along a surface of the housing. The connection port may be configured to interface with a catheter including a first electrode having a first length and a second electrode having a second length different from the first length. The housing may encase the electronic data storage and the one or more computer systems. The electronic data storage may include a plurality of stored patient profiles characterizing a plurality of patients. The act of directing power to the second electrode may direct an amount of power greater than the amount of power directed to the first electrode.

[0047] In some embodiments, the controller may comprise a housing, a user interface, an electronic data storage, and a computing device including one or more processors, the computing device being in communication with the electronic data storage and the user interface. The housing may comprise a connection port disposed along a surface of the housing, and a user interface disposed along a surface of the housing. The housing may cover the electronic data storage and the computing device. The connection port may be configured to interface with a catheter comprising a first electrode having a first length and a second electrode having a second length different from the first length. The computing device may be configured to at least accept a selection of the first electrode from the user interface and direct a first power level to the first electrode sufficient for ablation using the first electrode, and to accept a selection of the second electrode from the user interface and direct a second power level to the second electrode sufficient for ablation using the second electrode.

[0048] The computing device may be configured to simultaneously direct power to the first electrode and direct power to the second electrode. The computing device may be configured to direct power to the first electrode and direct power to the second electrode at different times. The computing device may be configured to interrupt power directed to the first electrode and direct power to the second electrode after power directed from the battery to the first electrode is interrupted.

[0049] The catheter may comprise an annular ring formed in an oval shape having a major axis and a minor axis. The major axis may have a first diameter along the major axis that is greater than a second diameter along the minor axis. The first electrode may be disposed across an apex of the major axis.

[0050] The controller may include a battery configured to store a first power level sufficient for ablation using the first electrode or a second power level sufficient for ablation using the second electrode. The housing may cover the battery. The computing device may be in communication with the battery and may be configured to direct power from the battery at a first power level sufficient for ablation using the first electrode and direct power from the battery at a second power level sufficient for ablation using the second electrode. The housing may include a power connection port configured to receive a level of power sufficient to charge the battery. The computing device may be configured to direct power from the battery to the first electrode after the battery has finished charging. The computing device may be configured to direct power from the battery to the second electrode after the battery has finished charging.

[0051] The catheter may include a first sensor connected to the first electrode. The computing device may be further configured to display first electrode ablation information acquired by the first sensor on a user interface while the computing device is directing power to the first electrode. The catheter may include a first sensor connected to the first electrode and a second sensor connected to the second electrode. The computing device may be configured to display first electrode ablation information acquired by the first sensor on a user interface while the computing device is directing power to the first electrode and to display second electrode ablation information acquired by the second sensor on a user interface while the computing device is directing power to the second electrode. The second electrode ablation information may be displayed on the user interface after the computing device stops directing power to the first electrode.

[0052] In some embodiments, a computer-implemented method may include, under the control of one or more computing devices executing certain computer-executable instructions, accepting a selection of a first electrode at a user interface disposed on a surface of the housing, directing power to the first electrode at a first power level sufficient for ablation using the first electrode, accepting a selection of a second electrode from the user interface, and switching from directing power to the first electrode to directing power to the second electrode at a second power level sufficient for ablation using the second electrode. The housing may include a catheter connection port disposed along a surface of the housing, the connection port configured to interface with a catheter comprising a first electrode (which may have a first length) and a second electrode (which may have a second length different from the first length). The housing may encase electronic data storage and one or more computing devices executing certain computer-executable instructions.

[0053] The switching may be performed using a mechanical switch with at least one moving part. The user interface may be a rotatable knob. The switching may be performed using a switching system that includes a mechanical switch with at least one moving part and a solid-state switch with no moving parts.

[0054] In some embodiments, a computer-readable non-transitory storage medium storing computer-executable instructions may be configured to cause one or more computer systems to perform operations when executed by the one or more computer systems. The operations may include accepting a selection of a first electrode from a user interface presented on an electronic display disposed on a surface of the housing, directing power to the first electrode at a first power level sufficient for ablation using the first electrode, and accepting a selection of a second electrode from the user interface, and switching from directing power to the first electrode to directing power to the second electrode at a second power level sufficient for ablation using the second electrode. The housing may include a connection port disposed along a surface of the housing. The connection port may be configured to interface with a catheter comprising a first electrode (having a first length) and a second electrode (having a second length different from the first length). The housing may encase the electronic data storage and the one or more computer systems. The switching may be performed by controlling a solid-state switch that does not include moving parts. 。 [Brief description of the drawings]

[0055] [Figure 1] FIG. 1 is a schematic structural diagram of an embodiment of a catheter according to the present invention.

[0056] [Diagram 2] FIG. 2 is a partially enlarged view of part B shown in FIG.

[0057] [Diagram 3] FIG. 3 is a schematic cross-sectional view taken along line 3-3 in FIG.

[0058] [Figure 4] FIG. 4 is a schematic diagram of the outer surface of an electrode that may be used with the catheter of FIG.

[0059] [Diagram 5] FIG. 5 is an elevational partial cross-sectional view of the human heart.

[0060] [Figure 6] FIG. 6 is a schematic partial view of the pulmonary trunk, which includes the distal portion of the main pulmonary artery and the proximal portions of the left and right pulmonary arteries.

[0061] [Figure 7A] FIG. 7A is a diagram of the inner surface of a dissected flattened dog pulmonary artery. [Figure 7B] FIG. 7B is a diagram of the inner surface of a dissected flattened dog pulmonary artery.

[0062] [Figure 8] FIG. 8 is a schematic diagram showing segmentation of the dissected pulmonary artery, including the distal portion of the main pulmonary artery and the proximal portions of the left and right pulmonary arteries.

[0063] [Figure 9] FIG. 9 is an illustration of the three segmentations shown in FIG.

[0064] [Figure 10A] FIG. 10A is an enlarged microscopic slide corresponding to the portion of the right pulmonary artery designated S1 at level A1 in FIG. [Figure 10B] FIG. 10B is an enlarged microscopic slide corresponding to the portion of the right pulmonary artery at level A1 designated as S2 in FIG. [Figure 10C] FIG. 10C is an enlarged microscopic slide corresponding to the portion of the right pulmonary artery at level A1 designated as S3 in FIG. [Figure 10D] FIG. 10D is an enlarged microscopic slide corresponding to the portion of the right pulmonary artery at level A1 in FIG. 9 designated as S4.

[0065] [Figure 11] FIG. 11 is a micrograph of the section of the main pulmonary artery designated S6 at level A9 in FIG.

[0066] [Figure 12] FIG. 12 is a posterior perspective view of the model of the left pulmonary artery of FIGS. 7A and 7B.

[0067] [Figure 13] FIG. 13 is an anterior view of the left pulmonary artery of FIG.

[0068] [Figure 14A] FIG. 14A shows locations corresponding to microscopic observations of six different locations at level A9 of the main pulmonary artery in FIG.

[0069] [Figure 14B] FIG. 14B is a table showing the reduction in pulmonary artery pressure (PAP) obtained using different ablation operating parameters.

[0070] [Figure 15A] FIG. 15A is a perspective view of a catheter that may be used to perform pulmonary denervation.

[0071] [Figure 15B] FIG. 15B is an enlarged end view of the distal end of the catheter of FIG. 15A with markings indicating the locations of the ten RF electrodes.

[0072] [Figure 15C] FIG. 15C is a perspective view of a controller that may be used to control the catheter of FIG. 15A during an ablation procedure.

[0073] [Figure 15D] FIG. 15D is a top plan view of the controller of FIG. 15C.

[0074] [Figure 15E] FIG. 15E is a perspective view of a controller connected to the catheter of FIG. 15A.

[0075] [Figure 16A]FIG. 16A is a fluoroscopic image of a sheath device inserted into the main pulmonary artery to guide the catheter of FIG. 15A into the main pulmonary artery.

[0076] [Figure 16B] FIG. 16B is a further fluoroscopic image of the catheter of FIG. 15A inserted and expanded within the left pulmonary artery of a human patient. [Figure 16C] FIG. 16C is a further fluoroscopic image of the catheter of FIG. 15A inserted and expanded within the left pulmonary artery of a human patient. [Figure 16D] FIG. 16D is a further fluoroscopic image of the catheter of FIG. 15A inserted and expanded within the left pulmonary artery of a human patient, illustrating the location used for ablation and arterial denervation of the patient's left pulmonary artery.

[0077] [Figure 16E] FIG. 16E illustrates the catheter of FIG. 15A positioned within a patient's main pulmonary artery in a location to be used for ablation.

[0078] [Figure 16F] FIG. 16F illustrates the catheter of FIG. 15A positioned proximal to the right pulmonary artery and pressed to determine whether the catheter is properly positioned for ablation purposes. [Figure 16G] FIG. 16G illustrates the catheter of FIG. 15A positioned proximal to the right pulmonary artery and retracted to determine whether the catheter is properly positioned for ablation purposes.

[0079] [Figure 16H] FIG. 16H is a fluoroscopic image of the catheter of FIG. 15A in position to perform an ablation in the proximal portion of the right pulmonary artery.

[0080] [Figure 17A] FIG. 17A is a schematic diagram of the pulmonary trunk showing locations for ablation in the distal portion of the main pulmonary artery.

[0081] [Figure 17B] FIG. 17B is a schematic diagram of the pulmonary trunk showing locations for ablation in the proximal portions of the left and right pulmonary arteries.

[0082] [Figure 18A] FIG. 18A is a schematic diagram of the pulmonary trunk showing locations for ablation in the portion of the left pulmonary artery proximal to the pulmonary duct.

[0083] [Figure 18B] FIG. 18B is a schematic diagram of an ablation spot on the anterior wall of the ablation location shown in FIG. 18A.

[0084] [Figure 19A] FIG. 19A is a schematic diagram of the pulmonary trunk showing locations for ablation in the proximal portion of the right pulmonary artery for treatment of unilateral chronic thromboembolism.

[0085] [Figure 19B] FIG. 19B is an enlarged schematic view of the portion indicated in FIG. 19A, showing the location for ablation in the anterior wall of the proximal portion of the right pulmonary artery.

[0086] [Figure 20] FIG. 20 is a schematic diagram of the pulmonary trunk, which includes the distal portion of the main pulmonary artery and the proximal portions of the left and right pulmonary arteries.

[0087] [Figure 21] FIG. 21 is a schematic diagram of an ablation option point along level C shown in FIG. 20, proximate the transition from the left side wall of the main pulmonary artery to the inferior wall of the proximal portion of the left pulmonary artery.

[0088] [Figure 22A] FIG. 22A is an enlarged perspective view of a further embodiment of the catheter of FIGS. 1 and 15A, with markings indicating the locations of the five RF electrodes.

[0089] [Figure 22B] FIG. 22B is an enlarged perspective view of a further embodiment of the catheter of FIG. 22A having three electrodes.

[0090] [Figure 23A] FIG. 23A is an angiographic image illustrating portions of a PADN procedure. [Figure 23B] FIG. 23B is an angiographic image illustrating portions of the PADN procedure. [Figure 23C] FIG. 23C is an angiographic image illustrating portions of the PADN procedure.

[0091] [Figure 24A] FIG. 24A is a chart illustrating 6-minute walk distance (6MWD) minus baseline 6MWD at 6-month follow-up in medical treatment and PADN surgery.

[0092] [Figure 24B] FIG. 24B is a chart illustrating how 6MWD after PADN correlates to medication therapy.

[0093] [Figure 24C] FIG. 24C is a chart illustrating how the improvements in hemodynamics and cardiac function were maintained during the one-year follow-up after PADN.

[0094] [Figure 25A] FIG. 25A is a perspective view of a digital ablation controller. [Figure 25B] FIG. 25B is a perspective view of the digital ablation controller. [Figure 25C] FIG. 25C is a perspective view of a digital ablation controller. [Figure 25D] FIG. 25D is a screenshot of the user interface of the digital ablation controller. [Figure 25E]FIG. 25E is a screenshot of the user interface of the digital ablation controller. [Figure 25F] FIG. 25F is a screenshot of the user interface of the digital ablation controller. [Figure 25G] FIG. 25G is a screenshot of the user interface of the digital ablation controller. [Fig. 25H] FIG. 25H is a screenshot of the user interface of the digital ablation controller.

[0095] [Figure 26] FIG. 26 is a schematic diagram illustrating a mechanical switching system that may be implemented in the controller of FIGS. 25A-25H or the controller of FIGS. 15C-15D.

[0096] [Figure 27] FIG. 27 is a schematic diagram illustrating a solid-state switching system that may be implemented in the controller of FIGS. 25A-25H or the controller of FIGS. 15C-15D.

[0097] [Figure 28] FIG. 28 is a diagram illustrating a general purpose switching system that may be implemented in the controller of FIGS. 25A-25H or the controller of FIGS. 15C-15D. DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0098] The following examples further illustrate the embodiments of the present invention, but should not be construed as limiting the present invention. Modifications or substitutions of the methods, steps, or conditions of the embodiments disclosed below without departing from the spirit and essence of the present invention are also within the scope of the present invention.

[0099] Unless otherwise specified, the technical means used in the embodiments are conventional means well known to those skilled in the art. EXAMPLES

[0100] With reference to the following examples and FIGS. 1-3, some of the technical solutions that can be achieved by various embodiments are further described below.

[0101] In some embodiments, a multipolar simultaneous pulmonary artery radiofrequency ablation catheter for desympathetic nerve ablation in the pulmonary artery can include a catheter body 1 having a distal end and a proximal end. The distal end can include a flexible end 3 and the proximal end can include a control handle 2. A pull wire can extend within the catheter body.

[0102] Preferably, the catheter body may be made from a polymeric material with low thermal conductivity, thereby preventing or reducing the amount of heat transferred from the electrodes to the blood stream in contact with the catheter body, thereby better preventing heating of the blood stream by the electrodes.

[0103] The flexible end 3 may include a proximal end and a distal end. An annular ring 4 may be disposed at the distal end. The flexible end 3 may be more flexible than the remainder of the catheter body. The annular ring 4 may include a plurality of electrodes 5, each of which may be configured to sense or extract neuro-electrical signals, sense temperature, and perform ablation. Each of the electrodes may be connected to a lead and a temperature sensing wire that extends through the catheter body to the control handle, and thus each of the electrodes is electrically connected to the control handle. To accurately monitor temperature during ablation, one or more temperature sensing wires may be embedded under each electrode. Additionally, in some embodiments, the temperature sensing wires may be connected to a thermocouple connected to the interior-facing side of the electrode 5 or may include an integrated thermocouple. Other configurations are also possible.

[0104] According to several embodiments, ablation may be performed by the electrode 5 using radio frequency (RF) energy to ablate sympathetic nerve fibers resulting in the disruption or neuromodulation of sympathetic neurotransmission. In some embodiments, the electrode 5 may ablate sympathetic nerve fibers using ultrasonic energy. In some embodiments, the electrode 5 selectively ablates sympathetic nerve fibers using ultrasound (e.g., high intensity focused ultrasound or low intensity focused ultrasound) energy. In other embodiments, the electrode 5 modulates sympathetic nerve fibers using electroporation.

[0105] However, the electrode 5 as used herein is not limited to causing ablation, but also includes devices that facilitate nerve modulation (e.g., partial or reversible ablation, blockage without ablation, or stimulation). In some embodiments, the catheter may modulate nerve fibers (e.g., via chemical ablation) using a drug administered at the location of the electrode 5 to the nerve fibers. Chemicals used in chemical ablation (or any other form of chemically mediated neuromodulation) may include, for example, phenols, alcohols, or any other chemicals that cause chemical ablation of nerve fibers. In some embodiments, cryotherapy is used. For example, the catheter may selectively modulate (e.g., ablate) sympathetic nerve fibers using a drug administered at the location of the electrode 5 for cryoablation. In other embodiments, the catheter may modulate nerve fibers using brachytherapy. The catheter may further use any combination of RF energy, microwave energy, ultrasonic energy, focused ultrasound (e.g., HIFU, LIFU) energy, ionizing energy (such as X-rays, protons, gamma rays, electron beam, and alpha rays), electroporation, drug delivery, chemical ablation, cryoablation, brachytherapy, or any other physical therapy to cause destruction or neuromodulation (e.g., ablation, denervation, stimulation) of autonomic (e.g., sympathetic or parasympathetic) nerve fibers.

[0106] According to some embodiments, a neuromodulation system is used to modulate or disrupt sympathetic nerve fibers at one or more locations or target sites. For example, the catheter may ablate in a circumferential pattern (such as using annular ring 4) or a radial pattern, and / or the catheter may ablate at multiple linearly spaced points along the length of the blood vessel. In other embodiments, the catheter ablates at one or more locations in any other pattern (e.g., helical pattern, zigzag pattern, multi-linear pattern, etc.) that may cause disruption of sympathetic nerve fiber pathways. The pattern may be continuous or non-continuous (e.g., intermittent). The ablation may target a portion of the circumference of the blood vessel (e.g., half or less than half the circumference).

[0107] A shape memory wire may be disposed within the annular ring 4, and a distal end of the shape memory wire may extend to the distal end of the annular ring 4. A proximal end of the shape memory wire may be fixed to the distal end of the flexible end 3. The shape memory wire within the annular ring 4 is preferably made from various shape memory alloys, such as nickel-titanium alloy, stainless steel, or titanium, having a diameter in the range of 0.25-0.5 mm.

[0108] The diameter of the annular ring 4 is within a range of 12-40 mm. For example, a shape memory wire may be configured to bias the annular ring 4 to a desired diameter, such as within a range of 12-40 mm. Additionally, in some embodiments, a pull wire may be used to change or adjust the diameter of the annular ring 4 across a range of diameters, including 12-40 mm or other ranges.

[0109] The length of the flexible end 3 may be in the range of 30-80 mm and may be made of medical polymeric materials such as fluorine, polyester, polyurethane, polyamide, and polyimide. A counterbore may be disposed at the distal end of the flexible end 3, and the proximal end of the annular ring may be fixed within the counterbore, with the proximal end of the annular ring being a thin ground end.

[0110] A pull wire may be embedded in the catheter body, and one end of the pull wire may be fixed to a control handle. The curvature of the flexible end 3 may be controlled by operating the control handle. For example, one end of the pull wire may be fixed to a control button on the handle, and the curvature of the flexible end 3 may be controlled by operating the button. This allows an operator to control the handle with one hand to easily adjust the curvature of the flexible end 3, so that the electrode 5 on the annular ring 4 can be pushed in to contact the pulmonary artery and acceptable ablation of the pulmonary artery intima can be achieved.

[0111] Furthermore, a counterbore can be made on the distal end of the flexible end 3, the depth of which can be set according to actual needs, preferably within the range of 2-8 mm. The proximal end of the annular ring 4 can be a thin ground end, the outer diameter of which matches the inner diameter of the counterbore. The thin ground end can be inserted into the flexible end 3 and fixed to the distal end of the flexible end 3 by gluing, welding, or other suitable means, preferably ultraviolet curing adhesive. An excess amount of adhesive may be used to seal the distal end of the flexible end 3 and the proximal end of the annular ring 4.

[0112] 1 shows a schematic structural diagram of a multipolar simultaneous pulmonary artery radiofrequency ablation catheter. The annular ring 4 may be disposed at the distal end of the flexible end 3. The annular ring 4 may have a ring structure, and the radius of the annular ring 4 may be acted upon by a shape memory wire.

[0113] The annular ring 4 may comprise a plurality of electrodes 5. Each electrode 5 may be configured to extract or detect neuro-electrical signals, sense temperature, and perform ablation. The number of electrodes 5 may vary from 3 to 30, preferably from 5 to 20. The electrodes 5 are made of platinum-iridium alloy, gold, stainless steel, or nickel alloy. The electrode diameter may be approximately 1.3 to 2.0 mm, and the length of the electrodes 5 may be approximately in the range of 1.2 to 4 mm, more suitably 2 to 3.5 mm. The space between the ends of adjacent electrodes may suitably be in the range of 0.5 to 10 mm, more suitably 1 to 5 mm.

[0114] The pull wire 8 may preferably be made of stainless steel or nickel-titanium. As shown in Figures 2 and 3, the distal end of the pull wire 8 may extend through the hollow cavity 9 to the proximal end of the annular ring 4 and be secured to the distal end of the flexible end 3. The method used to secure the pull wire 8 to the distal end of the flexible end 3 may be any method known in the prior art.

[0115] Optionally, a groove may be placed at the distal end of the flexible end 3 and a connector 11 may be placed in the groove. One end of the connector 11 may be connected to the pull wire 8 and the other end of the connector 11 may be connected to the shape memory wire 12. The connector 11 may be secured to the distal end of the flexible end 3 by injecting an adhesive, such as a UV-curable adhesive, into the groove.

[0116] A portion of the pull wire 8 extends into the flexible end 3 and a portion of the pull wire 8 extends into the catheter body 1. The pull wire may preferably be covered with a coil spring 13, which may be covered with a spring sleeve 14. The spring sleeve 14 may be made from any suitable material, preferably a polyimide material.

[0117] The proximal ends of the pull wires 8 may be fixed on or within the control handle 2, which may include an adjustment device. The adjustment device may be configured to adjust the curvature or diameter of the annular ring 4.

[0118] As shown in Figures 2 and 3, the leads 6 extend through the lead cavity 10 to the lead cavity of the annular ring 4. The distal ends of the leads 6 may be connected to the electrodes 5. The distal ends of the leads 6 may be secured to the electrodes 5 by welding. In some embodiments, the catheter includes one lead 6 for each of the electrodes 5.

[0119] The distal end of the temperature sensing wire 7 may be embedded under the electrode 5, or the distal end of the temperature sensing wire 7 may be secured to the electrode 5 by gluing, welding, or other suitable means. The temperature sensing wires 7 may enter the catheter body 1, extend into the lead cavity 10 in the flexible end 3, and exit the control handle 2 for connection to a temperature control device. In some embodiments, the catheter includes one temperature sensing wire 7 for each of the electrodes 5.

[0120] In use, the pull wires 8 can be manipulated via the control handle 2 to deflect the flexible end 3, thereby providing the user with increased control in positioning the annular ring 4 at a desired location, such as the opening of the pulmonary artery. The electrode 5 can then be energized to perform ablation on the pulmonary artery intima.

[0121] The multi-electrode design according to some embodiments can improve the efficacy and safety of ablation, and can achieve signal analysis and preferably simultaneous ablation by multiple electrodes, which can improve targeting accuracy, timely judge ablation effect, and reduce operation time. For example, with the annular ring 4 in the desired location, the electrodes can be individually actuated to perform ablation at selected sites. This is beneficial because in some methods of treatment described below, ablation can be performed at selected sites that are smaller than the entire circumferential surface of an anatomical structure. EXAMPLES

[0122] The multipolar simultaneous pulmonary artery radiofrequency ablation catheter includes a control handle 2, a catheter body 1, and an annular ring 4. The control handle 2 may include an adjustment device, and the catheter body 1 may be hollow and a cavity may be disposed within the catheter body 1. One or more lead wires 6, a temperature sensing wire 7, and a pull wire 8 may be disposed within the cavity.

[0123] One end of the catheter body may be flexible, and the flexible end 3 may be connected to the annular ring 4. The other end of the catheter body may be connected to the control handle 2. One end of a pull wire 8 may be connected to the flexible end 3, and the other end of the pull wire 8 may be connected to an adjustment device on the control handle, which adjusts the tension of the pull wire 3 to control the curvature of the flexible end. This allows an operator to easily adjust the curvature of the flexible end 3 by controlling the handle with one hand. This allows the electrode 5 of the annular ring 4 to be pressed against and better contact the inner surface of the desired anatomical structure, such as the pulmonary artery, to enhance ablation of the pulmonary artery intima.

[0124] A shape memory wire 12 may be disposed within the annular ring 4. One end of the shape memory wire 12 may extend to the tip of the annular ring 4, and the other end of the shape memory wire 12 may pass through the base of the annular ring 4 and be fixed to the flexible end 3 of the catheter body.

[0125] The annular rings 4 may include electrodes. Each electrode 5 may be connected to a lead 6 and a temperature sensing wire 7 and may be configured to extract or detect neuro-electrical signals, sense temperature, and perform ablation. The lead 6 and temperature sensing wire 7 may extend through the catheter body 1 and may be electrically connected to the control handle 2. The control handle 2 may be connected to an external temperature control device.

[0126] The annular ring electrodes 5 may be made of a material selected from the group consisting of platinum-iridium alloy, gold, stainless steel, and nickel alloy materials, the number of which is in the range of 3 to 30, the diameter is in the range of 1.3 to 2.0 mm, the length is in the range of 1.2 to 4 mm, and the end-to-end space between adjacent electrodes is in the range of 0.5 to 10 mm.

[0127] The flexible end 3 of the catheter body may have a counterbore 32. The outer diameter of the root of the annular ring 4 may match the inner diameter of the counterbore 32. The root of the annular ring 4 may be inserted into the counterbore 32 and secured thereto.

[0128] The flexible end 3 of the catheter body may include a groove. A connector 11 may be disposed in the groove. One end of the connector may be connected to a pull wire 8 and the other end of the connector may be connected to a shape memory wire 12.

[0129] The shape memory wire 12 may be made of a shape memory alloy such as nickel-titanium alloy, stainless steel, or titanium, with a diameter in the range of 0.25-0.5 mm. The diameter of the annular ring 4 may be in the range of 12-40 mm. Preferably 10 electrodes are placed on the annular ring, and the width of the bare (exposed) side of the electrodes may be 0.75 mm, with a space between them of 5 mm.

[0130] The flexible end 3 of the catheter body may be made from a medical polymeric material such as fluorine, polyester, polyurethane, polyamide, and polyimide, having a length within the range of 30 mm to 80 mm.

[0131] The connection may be made via a UV curable adhesive. The joint between the flexible end of the catheter body and the annular ring may be sealed. The pull wire 8 may be made of stainless steel or a nickel-titanium alloy. The pull wire 8 may be covered with a coil spring 13, which may be covered with a spring sleeve 14 made of a polyimide material. EXAMPLES

[0132] Example 3 is similar to Examples 1 and 2, with the difference being that it may include an infusion tube 22 disposed within the catheter body and a group of uniformly distributed through-holes 15 (FIG. 4) having a pore size of 1 μm disposed on one or more electrodes 5. One end of the infusion tube 22 may be connected to the electrodes 5 through the annular ring 4, thereby diffusing fluid from the through-holes 15 in each of the electrodes 5. For example, the annular ring 4 may include or define at least one lumen 24 extending between a proximal end of the annular ring 4 and the through-holes 15 to form a closed fluid connection. In such an embodiment, the distal end of the infusion tube 22 may be connected to a proximal end of the lumen 24 in the annular ring 4. The other end of the infusion tube 22 may be connected to an infusion system, such as a constant flow pump or other known pump.

[0133] When the electrode 5 generates a current, the liquid will automatically diffuse out of the through-holes 15. The infused liquid may be saline. Cold saline (4°C) perfusion can help to reduce the local temperature. When the electrode generates a current, the saline will automatically diffuse out of the through-holes 15, thereby controlling the local temperature to a desired temperature, such as below 60°C, thereby protecting the vascular intima.

[0134] FIG. 5 is a schematic diagram of a human heart and surrounding vasculature, which may be an environment in which the catheters of FIGS. 1-4 may be used to perform ablation therapy, such as, but not limited to, denervation of the pulmonary artery. In some treatment methods, access to the inner walls of the main pulmonary artery 502 and the left pulmonary artery 504 and right pulmonary artery 506 may be achieved by passing a catheter into the femoral vein and upward into the inferior vena cava 508 (lower left corner of FIG. 5) using well-known techniques. The catheter is then pushed upward into the right atrium 510, downward into the right ventricle 512, and upward through the pulmonary semilunar valve 514 into the trunk of the main pulmonary artery 502. As used herein, the term main pulmonary artery (MPA) 502 includes the most upstream end of the main pulmonary artery 502, from the proximal end of the main pulmonary artery at the pulmonary semilunar valve 514, to the bifurcation of the main pulmonary artery. The distal portion of the MPA includes the portion of the MPA 502 near the bifurcation of the MPA 502 into the left and right pulmonary arteries (LPA 504, RPA 506).

[0135] Similarly, the proximal end of the RPA 506 and the proximal end of the LPA 504 are the ends of the adjacent LPA 504 and RPA 506 that are connected to the distal end of the MPA 502. The distal direction along the LPA 504 and RPA 506 is the downstream direction in which blood flows through the LPA 504 and RPA 506, respectively, to the left and right lungs.

[0136] Thus, catheters can be used using well known techniques to provide access to the proximal and distal portions of the MPA 502 and the proximal and distal portions of the LPA 504 and RPA 506.

[0137] Figure 6 is a schematic diagram of the pulmonary artery "trunk." As used herein, the "trunk" of the MPA 502 includes at least a distal portion of the MPA 502 and proximal portions of the LPA 504 and RPA 506. Figure 6 also includes a schematic depiction of the tracheal bifurcation 602 at the branching point of the LPA 504 and RPA 506 from the MPA 502.

[0138] As described below, at least some aspects of the invention disclosed herein include the understanding that the pulmonary trunk of certain animals, including dogs and humans, may include a concentrated bundle of sympathetic nerves extending from the MPA 502 to the LPA 504 and RPA 506. For example, it has been discovered that there is a greater concentration of sympathetic nerves in the anterior aspect of the MPA 502, particularly near the distal portion of the MPA 502. In addition, it has been discovered that the sympathetic nerves bifurcate from this more concentrated area to the anterior side of the proximal portions of the LPA 504 and RPA 506. In these proximal areas, it has also been discovered that the more concentrated sympathetic nerves extend upward and to the posterior side of the LPA 504 and RPA 506.

[0139] Thus, according to some of the inventions disclosed herein, ablation is performed at the distal portion of the MPA 502 and the proximal portions of the LPA 504 and RPA 506. In some embodiments, ablation is performed preferentially at the anterior side of the inner walls of these structures. In some embodiments, ablation is performed preferentially at the anterior side of the proximal portion of the MPA 502 and at the superior and anterior portions of the proximal portions of the LPA 504 and RPA 506, for example, approximately at the superior connection site of the distal portion of the MPA 502 at the LPA 504 and RPA 506. Thus, sympathetic denervation can be achieved with high success rates, and symptoms of pulmonary hypertension can be reduced or eliminated with high success rates.

[0140] It is widely accepted that all vascular walls are controlled by the sympathetic and parasympathetic nervous systems. In particular, pulmonary vessels are known to be innervated by sensory nerve fibers. Previous studies have shown that the sympathetic noradrenergic innervation density along the pulmonary artery is highest in its proximal segment and decreases toward the periphery. This is a typical finding that differs from the arteries of other organs, where the highest innervation density is found at the level of the smallest arterioles. However, the conclusions of the above studies are based on techniques where the identification of innervation in the pulmonary artery is mainly based on sympathetic nerve stimulation or equivalent methods, and not on direct evidence or other locations of sympathetic nerve fibers. However, by using techniques to identify the presence and location of sympathetic nerves in the pulmonary artery using direct labeling techniques, some of the conclusions of the above studies have been found to be incorrect.

[0141] Specifically, the experimental procedures were approved by the Institutional Animal Care and Use Committees of Nanjing Medical University and were conducted in accordance with the National Guide for the Care and Use of Laboratory Animals. Mongolian dogs (n = 6, weighing 7.8 ± 1.2 kg) were obtained from Nanjing Experimental Center (Nanjing, China). All animals were kept in individual rooms at 24°C under a 12-h light / 12-h dark cycle and provided with fresh food and water.

[0142] In this study, dogs were anesthetized with sodium pentobarbital (60 mg per kg, intraperitoneal injection). The thorax was excised and carefully dissected. The entire pulmonary artery was removed from the thorax, taking special care not to damage the adventitia. In one dog, the pulmonary artery was dissected longitudinally along the direction of blood flow from the orifice of the main pulmonary artery (proximal part of the main pulmonary artery) to the left and right branches. To check whether there were visible differences in the surface of the pulmonary artery between different segments, it was photographed using a vernier focus camera.

[0143] In five other dogs, the connective tissue system was manually dissected from the pulmonary artery using fine microdissection scissors under the guidance of a stereomicroscope. Extreme care was taken during this procedure to avoid stripping the adventitia and damaging the nerves surrounding the vessels. The vessels were stored at -70°C for further staining.

[0144] Frozen vessels were processed in paraffin wax, fixed in 4% paraformaldehyde for 30 min, and then incubated in 0.5% Pontamine Sky Blue (Sigma-Aldrich, St. Louis, MO) in phosphate-buffered saline (PBS) for 30 min to reduce background fluorescence. They were then placed in a blocking solution of 4% normal goat serum / 0.3% TritonX-100 in PBS for 1 h at room temperature, and then placed in a blocking solution containing affinity-purified polyclonal antibody against tyrosine hydroxylase (Temecula, CA) overnight at 4°C. The vessel segments were then washed in PBS, incubated in secondary antibody (Invitrogen, Carlsbad, CA) for 1 h, washed again, and placed on glass slides. The specimens were left submerged in PBS to maintain hydration and vessel morphology during imaging.

[0145] Based on previous studies, it was believed that sympathetic nerves were mainly localized in the proximal segment of the pulmonary artery. Therefore, the distal segment of the main pulmonary artery (5 mm long) and the proximal 5 mm segments of its left and right branches were selected for investigation in this study. Figure 6 shows a schematic illustration, not to scale, of the 5 mm segment of the distal part of the MPA and the 5 mm long proximal parts of the LPA and RPA.

[0146] Transverse slices (2 μm thick) of the vessel were cut at 1.6 mm intervals and identified according to the labels in Figure 8 (A1, A2, A3, A4, A5, A6, A7, A8, A9, A10, A11, A12) as follows: The luminal morphology of the slices was carefully matched to the vessel contour to precisely localize the location of the nerve. The slices were examined by a pathologist.

[0147] Images of each slice were recorded (magnification 40x–200x) using a stereomicroscope (Olympus) and the total number of sympathetic nerve bundles (SPNDs) per level was calculated manually. All images were then entered into Image Analysis Software (Image-proplus 5.0) to determine the minor axis (μm), major axis (μm), and total surface area (TSA, μm) of the axonal area. 2 x10 3 ) was calculated.

[0148] The pulmonary artery was removed from the dog's chest and repeatedly washed with saline to remove all blood from the surface of the vessel. Then, the entire vessel was cut along the direction from the proximal part of the main pulmonary artery through the trunk into the left and right branches. The above-mentioned photographs (Figures 7A and 7B) show that there was an obvious raised cyst 702 on the anterior wall of the main pulmonary artery near the opening of the left pulmonary artery. The area of ​​the raised cyst 702 was firm to the touch compared to other areas of the pulmonary artery.

[0149] 5 mm long segments of the distal main pulmonary artery and the proximal left and right pulmonary arteries were examined near the bifurcation of the pulmonary artery. Four transverse slices (2 μm thick, 1.6 mm apart) from each segment were prepared for analysis. Each slice ("level") was divided into four subsegments (S1, S2, S3, S4 in Fig. 9) for the left and right pulmonary arteries and six subsegments (S1, S2, S3, S4, S5, S6 in Fig. 9) for the main pulmonary artery along the counterclockwise direction.

[0150] When examining these samples, we observed that more SPNDs 1002 were identified in the posterior wall of both the left and right pulmonary arteries. However, the number of SPNDs 1002 was significantly different (p = 0.033) in the S1 subsegment at the level of A5 in the left pulmonary artery branch, which was 1.6 ± 0.2, compared with 1.2 ± 0.2 in the S1 subsegment at the level of A1 in the right pulmonary artery. In contrast, more SPNDs 1002 were labeled in the anterior wall (S6) of the main pulmonary artery (Figure 11), which gradually decreased from levels A9 to A12.

[0151] The short and long diameters of sympathetic axons in the main pulmonary artery were 85 ± 2 μm and 175 ± 14 μm, respectively, compared with 65 ± 3 μm and 105 ± 12 μm, respectively, in the left pulmonary artery, and 51 ± 2 μm and 86 ± 8 μm, respectively, in the right pulmonary artery, indicating a large difference in axon surface area between the main pulmonary artery and the LPA and RPA (Fig. 9).

[0152] Based on the above observations, it was determined that in dogs, the sympathetic nerves are more concentrated along the anterior wall of the main pulmonary artery, extend to the right and left pulmonary arteries, and then extend upward and toward the posterior walls of the right and left pulmonary arteries, as shown diagrammatically in Figures 12 and 13.

[0153] Furthermore, examination of subsegment S6 at level A9 of the MPA (Fig. 11) (magnification 200x) revealed that a bundle or main bundle of sympathetic nerves originates approximately in the middle of the anterior wall of the distal part of the main pulmonary artery and that this main bundle bifurcates into the right and left pulmonary arteries.

[0154] This discovery provides the basis for more effective denervation of the pulmonary artery. For example, by selectively ablating only a portion of the main pulmonary artery and the left and right pulmonary arteries, a higher success rate of denervation can be achieved while reducing unnecessary tissue damage. Such denervation could have significant benefits in the treatment of diseases such as pulmonary hypertension, as described below.

[0155] With regard to pulmonary hypertension disease, it is well known that the lungs receive axons from the first five thoracic ganglia (including the stellate ganglion) of the sympathetic trunk as well as the main sympathetic neurons in the middle and lower neck, and the vasculature is the main sympathetic target in the lungs. Sympathetic stimulation increases pulmonary vascular resistance and decreases compliance. This is mediated by noradrenaline via a-adrenergic receptors, mainly the a1 subtype.

[0156] Previous studies have confirmed that multiple transmitters are released from a single nerve ending, and this multiplicity of transmitters may explain why pharmacological blockade of "classical" transmitters alone cannot effectively abolish the effects induced by nerve stimulation. The present study described above supports the concept that sympathetic denervation along the pulmonary trunk is more successful in the proximal segments of the right and left pulmonary arteries than in the distal basal trunk. Furthermore, percutaneous pulmonary denervation (PADN) may reduce pulmonary resistance and pressure induced by unilateral balloon occlusion in the interlobar arteries. However, until now, there has been no data showing the distribution of sympathetic nerves in the pulmonary trunk. Therefore, accurate identification of the location of sympathetic nerves is important for successful PADN. In this study, a very large bundle of sympathetic nerves was identified in the mid-anterior wall of the distal part of the main pulmonary artery, where it bifurcates into the posterior wall of the right and left pulmonary arteries. These results suggest that, as suggested by the animal studies mentioned above, performing one or more ablation procedures, e.g., by PADN procedure, especially around the distal parts of the main lung bifurcations and the proximal parts of the LPA and RPA, is likely to provide better results and more successful denervation.

[0157] Moreover, the density of sympathetic noradrenergic innervation is highest in extrapulmonary and hilar vessels (both arteries and veins) and decreases towards the periphery. This is in marked contrast to many other organs, where the highest innervation density is found at the level of the smallest arterioles. Such distribution differs from species to species according to the extent to which sympathetic noradrenergic axons reach into the lungs. In guinea pigs, rabbits, sheep, cats, dogs, and humans, small arterioles as small as 50 μm in diameter are innervated, whereas in rats, mice, hedgehogs, and badgers, noradrenergic innervation stops close to the lungs.

[0158] Although an extensive network of noradrenergic and NPY-containing fibers has been identified around the pulmonary arteries of several species, only a few studies have used double-labeling techniques to assess the extent of colocalization. In the guinea pig, nearly all noradrenergic fibers innervating the pulmonary arteries and veins contain NPY and, in addition, dynorphin, a neuropeptide of the opioid family. In this respect, pulmonary vascular innervation is clearly distinct from the innervation of cutaneous arteries in the same species, where three different combinations of noradrenaline, NPY, and dynorphin are used by sympathetic axons. Each of these populations is restricted to a specific segment of the arterial tree in the skin. Nevertheless, noradrenergic and NPY-containing fibers are not 1:1 in the lung, because there is a small population of axons innervating the guinea pig pulmonary arteries and veins that contain NPY and vasoactive intestinal peptide (VIP), but not noradrenaline. Whether this low-frequency population of fibers represents non-noradrenergic neurons projecting to the guinea pig lung or originates from another system remains to be determined.

[0159] The present study described above, which was performed by serially slicing the pulmonary trunk at various levels, demonstrates that a larger bundle of nerves is localized in the anterior wall of the main pulmonary artery and bifurcates along the posterior wall of the LPA and RPA into the left and right pulmonary arteries. The study was performed on the canine anatomy.

[0160] One of the diseases treatable with the present method and device is idiopathic pulmonary arterial hypertension (IPAH). IPAH is characterized by elevated mean pulmonary arterial pressure (PAP) and pulmonary vascular resistance (PVR). The pathogenesis of IPAH has been believed to be due to an imbalance between locally produced vasodilators and vasoconstrictors. Recent studies have demonstrated that remodeling of the vascular wall also contributes to elevated PVR. The role of neural reflexes in mediating and progressing IPAH has not been specifically investigated. The present animal study described above demonstrates that the PADN procedure can reduce or completely abolish the elevation of PAP induced by balloon occlusion in the interlobar segments but not in the basal trunks.

[0161] In a further aspect of this study, a human study was performed. Prior to enrollment, all 21 patients were administered a diuretic (hydrochlorothiazide, doses 12.5 mg to 25 mg, once daily and / or spironolactone, doses 20 mg to 40 mg, once daily) and beraprost (120 mg, four times daily) (Table 1), together with either sildenafil (20 mg, three times daily) or bosentan (120 mg, twice daily) or digoxin (0.125 mg, once daily). The patients' functional capacity was determined by the 6-minute walk test (6MWT), and then dyspnea was assessed using the Borg scale. The 6MWT was performed at 1 week, 1 month, 2 months, and 3 months after PADN surgery. The WHO classification at rest and during exercise was recorded by an internist blinded to the design of the study.

[0162] Echocardiographic examinations were performed at 1 week, 1 month, 2 months, and 3 months after surgery. Echocardiographic studies were performed using a Vivid 7 ultrasound system with standard imaging transducers (General Electric Co., Easton Turnpike, Connecticut, USA). All echocardiograms were performed and interpreted at the Medical University Echocardiographic Laboratory. All measurements were performed according to the recommendations of the American Society of Echocardiography. Digital echocardiographic data including a minimum of three consecutive beats (five beats in the case of atrial fibrillation) were acquired and stored. RV systolic pressure is equal to systolic PAP in the absence of pulmonary stenosis. Systolic PAP is equal to the sum of right atrial (RA) pressure and the systolic RV-RA pressure gradient. RA pressure was estimated based on the echocardiographic characteristics of the inferior vena cava and assigned a standard value. The RV-RA pressure gradient was calculated using a modified Bernoulli equation to obtain a 4v t 2 In the formula, v t is the velocity of tricuspid regurgitation in m / s. Mean PAP was estimated according to the velocity of pulmonary regurgitation in m / s. Tricuspid excursion index (TEI) was defined as (AB) / B, where A is the time interval between the end and beginning of the tricuspid annular diastolic velocity and B is the duration of the tricuspid annular systolic velocity (or RV ejection time). Patients' PA compliance was calculated as stroke volume divided by pulse pressure (systolic PAP-diastolic PAP).

[0163] Hemodynamic measurements and blood oxygen tension / saturation assessments were performed from the RA, RV, and PA before and immediately after PADN surgery. These measurements were repeated every 24 hours and every 3 months.

[0164] A 7F flow-directed Swan-Ganz catheter (131HF7, Baxter Healthcare Corp., Irvine, CA) was inserted into the internal jugular or subclavian vein. Measurements of resting RA pressure, RV pressure, systolic / diastolic / mean PAP, pulmonary artery occlusion pressure (PAOP), cardiac output (CO) (using thermodilution), and mixed venous oxygen saturation were recorded. PVR [= (mean PAP-PAOP) / CO] and transpulmonary gradient (TPG=mean PAP-PAOP) were then calculated. All measurements were recorded at the end of expiration. Five criteria were used to assess whether PAOP measurements were valid. (1) PAOP was less than diastolic PAP; (2) trajectory was comparable to atrial pressure waveform; (3) fluoroscopic image showed catheter in steady state after inflation; (4) free flow was present in the catheter (flush test); and (5) highly oxygenated blood (capillary) was obtained from the distal portion of the occlusion site. When PAOP measurements were unreliable, left ventricular end-diastolic pressure was measured and used instead of the PAOP. Blood samples from the SVC and pulmonary artery were obtained for oxygen tension and oxygen saturation measurements. By using temperatures above 50°C and applying an electrical load of 8-10 W for 60-120 s, particularly large reductions in systolic and mean PAP were achieved, as shown, for example, in Figure 14B.

[0165] The PADN procedure was performed using a dedicated 7.5F multifunction (temperature sensor and ablation) catheter. This catheter comprises two parts: a handle 2 (FIG. 15A) and a catheter shaft 3, which are an embodiment of the catheter illustrated in FIGS. 1-4. The catheter in FIG. 15A has a tapered (up to 5F) annular ring 4 with ten pre-loaded electrodes 5 (E1-E10). These electrodes 5 are spaced 2 mm apart from each other, although other spacings can be used. For the purposes of the following description, the electrodes 5 are numbered as shown in FIG. 15B, with the most distal electrode 5 being electrode E1 and the most proximal electrode 5 being electrode E10.

[0166] As discussed above with reference to Figures 1-4, the annular ring 4 or ("round tip") may be configured to be biased to a circular / circular shape, such as the circular shape illustrated in Figures 15B and 1, to have a desired outer diameter. For example, in various embodiments, the annular ring 4 may be configured to be biased to a circular shape having an outer diameter of 20 mm, 25 mm, 30 mm, 35 mm, 40 mm, 45 mm, or other diameter. In addition, a kit including the catheter of Figure 1 may include a plurality of different annular rings 4 configured to be biased to a plurality of different outer diameters, as described above, or other diameters.

[0167] A controller or "junction box" may be connected to the catheter handle 2 to provide the ablation energy. For example, an ablation controller 100 may be configured to provide ablation energy to each of the electrodes E1-E10. Thus, in some embodiments, the controller 100 includes a selector knob 102 configured to allow a user to choose to activate all of the electrodes E1-E10, or to selectively activate individual electrodes E1-E10 one at a time.

[0168] Thus, in some embodiments, as illustrated in FIG. 15D, the selector knob 102 includes a position indicator 104. The position indicator 104 can be aligned with markings corresponding to the electrodes E1-E10 by rotating the knob 102. In the illustrated embodiment, the markings on the controller 100 include the numbers 1-10 as well as an "OFF" position and a "none" position. In some embodiments, the connection cable 106 can include multiple wires, for example ten wires corresponding to the lead wires 6 described above with reference to FIGS. 1-4, each wire individually connected to a respective electrode E1-E10.

[0169] The controller 100 may include a physical switch for making an electrical connection between a source of RF energy and a desired one of the electrodes E1-E10. An electrode (not shown) may be directly connected to the knob 102, with additional contacts (not shown) positioned around the electrode that generally correspond to positions 1-10 on the controller 100. Rotating the knob 102 thus connects an internal electrode (not shown) to the contacts aligned with each of positions 1-10.

[0170] The controller 100 may be configured to provide a desired amount of ablation energy when a circuit is formed by aligning the position indicator 104 with a corresponding position (1-10) on the controller 100, thereby delivering electrical energy to a selected one of the electrodes E1-E10, whereby the electrical energy is transmitted through the selected electrode 5 to any conductive material in contact with the selected electrode.

[0171] For example, during a PADN procedure, electrodes E1-E10 can contact the inner wall of the pulmonary trunk, thereby allowing electrical energy from one of electrodes E1-E10 to flow through the tissue of the inner wall of the pulmonary artery, as described in more detail below.

[0172] 15D, the controller 100 may include multiple ports. For example, the controller 100 may include a catheter port 120. The catheter port 120 may be configured to form a fluid connection to the annular ring 4 for the purpose of providing a flow of saline to the annular ring 4. The controller 100 may also include an RF port 122 configured to be connected to any known radio frequency generator used in connection with an ablation procedure.

[0173] Additionally, the controller 100 may include an "ECG" port 124 configured to connect to standard ECG monitoring equipment. Thus, in some embodiments, the connection cable 106 may also include wires or conduits for transmitting data via the RF port 124.

[0174] Thus, in some configurations, the RF port 122 may be connected to a source of RF energy (not shown). One or more wires (not shown) may connect the port 122 to contacts on the ends of the electrodes connected to the selector knob 102. In addition, ten wires (not shown) may be configured to deliver RF electrical energy to the electrodes E1-E10. Each of the electrodes E1-E10 may be connected to contacts (not shown) associated with selector positions 1-10 located around the periphery of the selector knob 102.

[0175] Thus, an electrode connected to the rotating selector knob 102 can be moved into contact with an electrical contact associated with each of positions 1-10, thereby forming a circuit connecting electrical energy entering the controller 100 via port 122 to the associated lead 6, so that the electrical energy can be conducted to the desired electrode E1-E10.

[0176] Thus, specifically, when the selector knob 102 is rotated so that the position indicator 104 is aligned with position 1 on the controller 100, electrical energy from the RF port 122 is conducted to electrode E1 via the associated lead 6. Aligning the indicator 104 with other positions on the controller 100 causes electrical energy to be conducted to other electrodes associated with those other positions.

[0177] In some embodiments, a method for treating pulmonary hypertension may include identifying the location of the patient's pulmonary trunk using an angiogram. For example, a baseline pulmonary artery angiogram may be performed to identify the location of the pulmonary artery bifurcation from the main pulmonary artery into the left and right pulmonary arteries.

[0178] In addition, the baseline pulmonary artery angiogram may be used to determine the diameter of the portion of the pulmonary trunk where ablation is desired. Thus, the appropriate diameter of the annular ring 4 may be determined based on the determined diameter of the pulmonary trunk as described above. For example, in some embodiments, an annular ring 4 having a biased diameter slightly larger than the diameter of the target anatomy may be used to enhance contact between the electrode 5 and the inner surface of the target anatomy. Thus, for example, when the annular ring 4 is expanded out of the sheath 1602 into a biased circumferential configuration having an outer diameter slightly larger than the inner diameter of the target portion of the pulmonary trunk, the bias of the annular ring 4 aids in pressing the electrode 5 into contact with the target tissue.

[0179] In some embodiments, with reference to Figures 16A-16H, a method may include positioning a catheter in the pulmonary trunk. For example, as shown in Figure 16A, a sheath 1602 may be inserted via the femoral vein and advanced into the main pulmonary artery. A catheter, such as the catheter illustrated in Figures 1 and 15A-15E, may be advanced along the sheath 1602 shown in Figure 16A to a location in the pulmonary trunk.

[0180] With the distal end of the catheter held in place, the sheath 1602 can be withdrawn. It may be necessary to push the catheter to maintain its position while keeping the portion of the catheter that forms the annular ring 4 within the pulmonary trunk.

[0181] As illustrated in FIG. 16B, when the annular ring 4 is released from the sheath 1602, the annular ring 4 is able to assume the shape and diameter that is dependent on the bias to which it is subjected.

[0182] By slightly rotating and pushing the handle 2 in a clockwise direction, the annular ring 4 can be positioned at a proximal portion of the left pulmonary artery, such as at the ostium. In some embodiments, this initial position can be within approximately 5 mm, or within 2 mm, of the opening of the left pulmonary artery, as illustrated in FIG. 16D.

[0183] By observing the orientation of the annular ring 4, the desired electrode or electrodes E1-E10 can be selectively energized to ablate at a desired location on the inner surface of the left pulmonary artery. For example, in some embodiments, it may be more effective to selectively ablate the posterior wall of the left pulmonary artery to achieve at least some sympathetic denervation of the left pulmonary artery and of a small proximal portion of the left pulmonary artery, such as within 2 mm or 5 mm of the ostium of the left pulmonary artery.

[0184] The annular ring 4 can then be rotated, for example in a counterclockwise direction, by rotating and pulling back the handle 2 to reposition the annular ring 4 in the distal portion of the main pulmonary artery, for example in the area of ​​the bifurcation. For example, in some embodiments, the annular ring 4 can be positioned within about 5 mm of the bifurcation in the pulmonary trunk, as illustrated in FIG. 16E. Ablation can then be performed using the desired electrode or electrodes E1-E10.

[0185] For example, once so positioned, a selected electrode or electrodes E1-E10 can be energized to achieve the desired sympathetic denervation of the distal portion of the main pulmonary artery, in some embodiments, it may be desirable to preferentially ablate the anterior wall of the distal portion of the main pulmonary artery.

[0186] Additionally, by further rotating and pushing the handle 2, the annular ring 4 can be positioned at a proximal portion of the right pulmonary artery, such as at the ostium. In some embodiments, this location can be within 5 mm of the ostium of the right pulmonary artery. Further, in some embodiments, this location can be within 2 mm of the ostium of the right pulmonary artery.

[0187] With the annular ring 4 so positioned, the desired electrode or electrodes E1-E10 may be energized to achieve at least some sympathetic denervation in the proximal portion of the right pulmonary artery. For example, in some embodiments, it may be beneficial to focus on the posterior wall of the right pulmonary artery.

[0188] In some embodiments, the method for treating pulmonary hypertension may include a step of confirming proper contact between the intravascular surface and the electrodes E1-E10 corresponding to the three positions described above. For example, in some embodiments, such confirmation may be performed by determining whether a strong resistance is felt in the hand when attempting to rotate the handle 2. In addition, it may be determined whether the annular ring 4 cannot be advanced distally, resulting in a deformation of the catheter as illustrated in FIG. 16G, or whether it is easy to pull back proximally, resulting in a deformation of the catheter as illustrated in FIG. 16H. In addition, confirmation may be performed using angiographic confirmation.

[0189] After the annular ring 4 is positioned as desired, for example, in a position illustrated in Figures 16D, 16E, and 16F, at least one of the electrodes E1-E10 may be energized to perform ablation. For example, in some embodiments, a method for treating pulmonary hypertension may include sequentially energizing each of the electrodes E1-E10.

[0190] Additionally, in some embodiments, a method for treating pulmonary hypertension or for performing pulmonary denervation may include repositioning the annular ring 4 to shift the location of electrodes E1-E10 and then repeating energization of all of electrodes E1-E10, thus achieving a more complete denervation of the entire inner surface of the associated blood vessel.

[0191] In some embodiments, ablation can be performed using electrodes E1-E10 described above using any desired energy level or temperature. For example, in some embodiments, ablation can be performed using an electrical load of 8-10 W for 60-120 seconds at a temperature above 50° C. Additionally, in some embodiments, the method for treating pulmonary hypertension or the method for performing sympathetic denervation of the pulmonary artery can be performed while the patient is anesthetized but conscious. Thus, if the patient complains of intolerable chest pain, the ablation procedure can be stopped.

[0192] In some embodiments, EKG and hemodynamic pressures can be monitored and recorded continuously throughout the method. In studies performed according to the above description, success was defined as a decrease in mean PAP > 10 mmHg (measured by Swan-Ganz catheter). No complications occurred during the study. In addition, patients were monitored in the coronary care unit (CCU) for at least 24 hours after the PADN procedure was performed.

[0193] For example, in some embodiments of the methods disclosed herein, a dedicated 7.5F triple function catheter (A) may be used, which may include a tapered annular ring 4 with 10 electrodes 5 (each electrode having a 0.75 mm electrode width, spaced 2 mm apart, and pre-loaded). The electrodes are connected to a connection cable 106 and a junction box / controller 100. On the face of the controller 100 are 10 positions of a knob 102 (FIG. 15D), each associated with one of the electrodes E1-E10 on the annular ring 4 of the ablation catheter. After the entire system is set up, sequential ablations can be performed by rotating the knob 102 as desired. In certain embodiments, ablation is paused while switching from one electrode to the other.

[0194] In some embodiments, the method for performing pulmonary artery denervation or primary PAH ablation treatment of the distal portion of the main pulmonary artery may be performed preferentially on its anterior side. For example, in some embodiments, ablation may be performed at the M1, M2, M3, M4, and M5 locations, as shown in FIG. 17A.

[0195] Continuing with reference to Figure 17A, the M1 location is the "6 o'clock" position of the distal portion of the main pulmonary artery. The M3 and M5 locations are where the anterior wall of the main pulmonary artery joins the left and right pulmonary arteries, respectively. The M2 and M4 locations are the "5 o'clock" and "7 o'clock" positions anterior to the distal portion of the main pulmonary artery.

[0196] In some embodiments, referring to FIG. 17B, sympathetic denervation in the left and right pulmonary arteries may be preferentially performed approximately at the middle of the anterior wall of the proximal portion of the left pulmonary artery (L1) and approximately at the upper connection site of the distal portion of the main pulmonary artery to the left pulmonary artery (L2).

[0197] Similarly, during the method of pulmonary denervation of the right pulmonary artery, ablation may be preferentially performed at a point approximately in the middle of the anterior wall of the proximal portion of the right pulmonary artery (L3) and approximately at the upper junction of the distal portion of the right pulmonary artery and the main pulmonary artery (L4).

[0198] In some embodiments, sympathetic denervation may be performed, for example, for the treatment of pulmonary hypertension associated with the pulmonary duct artery (PDA) 1802. For example, as shown in FIGURE 5, the pulmonary duct artery normally connects the descending aorta to the left pulmonary artery 504. Due to this anatomy, the left pulmonary artery may be significantly larger than the right pulmonary artery.

[0199] Thus, in some embodiments, ablation may be performed at a location proximal to the junction between the left pulmonary artery and the pulmonary duct, shown as "Level A" in Figure 18A. Thus, using the techniques described above with reference to Figures 16A-16H, the annular ring 4 may be positioned at a location corresponding to "Level A" in Figure 18B. At that location, ablation may then be performed around some or all of the inner wall of the left pulmonary artery.

[0200] In some embodiments, ablation may be performed preferentially in the anterior wall of the left pulmonary artery, proximal to the proximal end of the pulmonary artery. For example, ablation may be performed in four or more locations, as shown as locations L11, L12, L13, and L14. As illustrated in FIG. 18B, location L11 corresponds to "12 o'clock", location L12 corresponds to "2 o'clock", location L13 corresponds to "3 o'clock", and location L14 corresponds to "6 o'clock". Other locations may also be used.

[0201] Additionally, in some embodiments, ablation may also occur at locations M1-M5 illustrated in FIG. 17A and locations L1-L4 in FIG. 17B.

[0202] In some embodiments, the method for sympathetic denervation may be used to treat pulmonary hypertension resulting from unilateral chronic thromboembolism. For example, a patient with unilateral CTEH may have an obstructed right pulmonary artery. For example, some patients may have a highly enlarged RPA, as illustrated in the left side of FIG. 19A. Similar to the method described above with reference to FIG. 18B, ablation may be performed at the location shown as "Level B" in FIG. 19A. Ablation may be performed at one or more locations along the inner surface of the right pulmonary artery at the level B location or other locations. In addition, ablation may be performed at multiple points along the anterior wall of the right pulmonary artery, preferentially at the level B location.

[0203] For example, the positions shown in Figure 19B can be considered to be position L21 corresponding to "12 o'clock," position L22 corresponding to "2 o'clock," position L23 corresponding to "3 o'clock," and position L24 corresponding to "6 o'clock." Additionally, in some embodiments, ablation can also be performed at positions M1-M5 illustrated in Figure 17A, and positions L1 and L2 illustrated in Figure 17B.

[0204] With reference to Figure 20, further embodiments of the treatment of pulmonary hypertension may include selectively ablating portions of the pulmonary trunk in fewer ablation sites than in some of the embodiments described above. For example, Figure 20 shows the "Level C" ablation sites shown in Figure 21.

[0205] Referring to FIG. 21, an enlarged schematic diagram of “Level C” shown in FIG. 20 shows a plurality of ablation sites b 1、 b 2、 20. These ablation sites are grouped in a portion of the pulmonary trunk that is proximal to the left lateral wall of the upper end of the main pulmonary artery and proximal to the inferior wall of the proximal portion of the left pulmonary artery where these portions join. For example, as illustrated in FIG. 21, ablation site b1 is located approximately at the left lateral apex of the distal end of the main pulmonary artery, which is continuous with the inferior wall of the proximal end of the left pulmonary artery. In addition, ablation sites b2, b3 are located anterior and posterior to ablation site b1, respectively, along or approximately along "Level C" shown in FIG. 20. These ablation sites b1, b2, and b3 can be targeted to ablate specific bundle clusters of sympathetic nerves on the left lateral side of the distal end of the main pulmonary artery. These bundle clusters can be approximately 5 mm above the pulmonary valve 514 (FIG. 5) but below the tracheal bifurcation 602 (FIG. 6).

[0206] Figure 22A illustrates a further embodiment of the annular ring 4 illustrated and described above with reference to Figures 1 and 15B. The embodiment of the annular ring 4 illustrated in Figure 22A is designated by the reference numeral 204. The annular ring 204 illustrated in Figure 22A can be constructed in accordance with the description above with respect to the annular ring 4 and can be used with the handheld device 1 (Figure 1), except with respect to the differences described below.

[0207] As shown in FIG. 22A, the annular ring 204 may have fewer electrodes than those included in the annular ring 4 described above. In this illustrated embodiment, the annular ring 204 includes five electrodes 200, 205, 206, 208, 210. Additionally, the annular ring 204 is configured to be oval (or biased to be oval) when in the deployed / relaxed state. In the deployed / relaxed state, the annular ring 204 may be substantially planar. Also, in the deployed / relaxed state, the annular ring 204 may be substantially perpendicular or perpendicular to the portion of the flexible end 3 of the catheter body connected to the annular ring 204. As illustrated in FIG. 22A, in the deployed state, the annular ring 204 may have a diameter D1 along its major axis. The diameter D1 is greater than a second diameter D2 along the minor axis of the annular ring 204. Such a configuration results in the annular ring 204 being oval in the deployed state. The electrodes 200, 205, 206, 208, 210 of the annular ring 204 may have a size in space having the dimensions shown in FIG. 22A or other dimensions. Also, in certain embodiments, the annular ring 204 may be elliptical, and optionally may be substantially planar. Optionally, such an elliptical ring may not be a complete loop. For example, the distal end of the annular ring 204 may not turn 360 degrees back to the proximal end of the annular ring, but may turn at an angle less than 360 degrees (e.g., between 270 degrees and 359 degrees). In certain embodiments, the proximal end of the annular ring may be spaced apart by a distance of 3 mm, as illustrated in FIG. 22A, by not turning 360 degrees back to the proximal end of the annular ring 204.

[0208] With continued reference to FIG. 22A, the electrodes 206, 205, 208 may be positioned and sized to provide selective ablation of the pulmonary artery corresponding to the ablation sites b1, b2, b3 described above with reference to FIG. 21. Additionally, the electrodes 206, 205, 208 may have different sizes. In some embodiments, the electrode 206 may have a configuration and size that allows for denervation of site b1 and may be larger than the electrodes 205, 208. Additionally, in some embodiments, the electrode 205 may be larger than the electrode 208. For example, the electrode 206 for ablation at b1 may be 4 mm in length, while the electrode 205 for ablation at b2 may be 3 mm in length and the electrode 208 for ablation at b3 may be 2 mm in length. Other arrangements, configurations, and sizes may also be used. The electrode 206 for ablation at b1 may be positioned at the end of the diameter D1 and / or across the apex of the long axis of the annular ring 204.

[0209] With continued reference to FIG. 22A, the annular ring 204 can be constructed in multiple sizes. For example, FIG. 22A includes examples of diameters D1, D2 available for five different sizes of the annular ring 204. The diameters D1, D2 for these five different sizes can be combined in the following pairs of diameters (in millimeters): format (D1, D2): (25, 20), (30, 25), (35, 30), (40, 35), and (50, 45). Thus, in some embodiments, the diameter D1 is 5 mm larger than the diameter D2. Other sizes and ratios can also be used.

[0210] It is known that in at least some patients, pulmonary artery (PA) sympathetic denervation is mostly concentrated near the left proximal PA. Right PA sympathetic denervation may be less common. The vagus nerve may extend deep to the sympathetic nerve (relative to the PA).

[0211] In some embodiments, as described above, the effective reduction in PA hypertension (PAH) is observed only on the left side, approximately at location b shown with reference to FIG. 1、 b 2、 This can be achieved by performing ablation at three sites, such as at b1, b2, b3, and further ablations can be omitted. Thus, in some embodiments, ablations can be performed at or near ablation locations b1, b2, b3, and further ablations can be avoided or omitted.

[0212] Figure 22B illustrates a further embodiment of the annular ring 204 illustrated and described above with reference to Figure 22A. This embodiment of the annular ring 204 illustrated in Figure 22B is designated by the reference numeral 220.

[0213] As illustrated in FIG. 22B, in a deployed state, the annular ring 220 can have a diameter D3 along its major axis. The diameter D3 is greater than a second diameter D4 along the minor axis of the annular ring 220. With such a configuration, the annular ring 220 has an oval shape in its deployed state. For example, FIG. 22B includes examples of diameters D3, D4 available for five different sizes of the annular ring 220. The diameters D3, D4 for these five different sizes can be combined in the following pairs of diameters (in millimeters): Format (D3,D 4) : (25,20), (30,25), (35,30), (40,35), and (50,45). Thus, in some embodiments, diameter D3 is 5 mm larger than diameter D4. Other sizes and ratios can also be used.

[0214] The annular ring 220 may be configured to perform three site ablation with electrodes 206, 205, and 208 at approximately the locations b1, b2, b3 shown above with reference to Figures 21 and 22A. The electrode 206 for ablation at b1 may be located at the end of diameter D3 and / or across the apex of the annular ring 220. The electrodes 208, 206, and 205 of the annular ring 220 may be sized in space having the dimensions shown in Figure 22A or other dimensions.

[0215] In some embodiments, the tissue temperature is raised to 50° C. (range 48° C.-52° C.) by applying RF energy to three sites b1, b2, b3 for 2 minutes each, for example. As mentioned above, optionally, further ablation can be omitted.

[0216] The generator may be configured and operated to deliver 3-15 watts of RF energy. In some embodiments, it has been observed that by ablating the three sites b1, b2, b3 as described above, PA blood pressure may be immediately reduced by at least about 10%. Such physiological changes may be immediately fed back and used to further guide treatment.

[0217] In some animals, visualization of sympathetic nerves reveals thinning of axons after RF ablation. In humans with PAH and in animals (treated with MCHT to produce experimental PAH), there is evidence of vascular remodeling with HTN-induced wall thickening 3 months after treatment. In some patients 1-2 years after treatment, the initial improvement in PAH continued for the interval after treatment.

[0218] The efficacy of PADN versus standard medical therapy for the treatment of PAH with different etiologies was investigated in an additional study. In this additional study, 28 patients with PAH were sequentially assigned to standard medication or PADN. PADN was associated with significant improvements in 6-minute walk distance (6MWD) and hemodynamics for 6 months after PADN. PADN was also associated with fewer PAH-related events 6 to 12 months after PADN.

[0219] A total of 28 patients (11 men, 17 women, mean age 49 years) were included in the additional study. As shown in Table 1, 8 patients had IPAH, 9 patients had PH due to LHD, 4 patients had connective tissue disease, 3 patients had chronic thromboembolic PH, and 4 patients had congenital heart disease after surgical treatment. The mean time interval from the diagnosis of PAH / PH to the present study was 4.24 years. During the drug holiday period, one LHD patient showed worsening symptoms requiring diuretic treatment. [Table 1]

[0220] Patients with WHO functional class II-IV PAH and mean PAP (mPAP) ≥ 25 mmHg at rest were included in this additional study. In particular, for patients with pulmonary hypertension (PH) due to left heart disease (LHD), further requirements included a pulmonary arterial obstructive pressure (PAOP) > 15 mmHg at rest and a pulmonary vascular resistance (PVR) > 2.5 Woods units. No patients had active inflammation or cancer. In addition, no patients had portal hypertension or PH due to drug or toxin exposure. The study protocol was approved by the Institute Research Board (Nanjing Medical University).

[0221] A five-half-life washout was performed for all patients. All patients who met the inclusion / exclusion criteria above were selected and entered the first drug-free period (defined as stopping all medications for at least five half-lives except warfarin). Right heart catheterization and adenosine testing were not performed for all patients before the study. Warfarin was prescribed continuously. Patients who could not tolerate warfarin were prescribed aspirin (100 mg / d) and Plavix (75 mg / d) instead of warfarin. Immediately after the PADN procedure, standard medications for PAH were stopped for all patients.

[0222] If the patient was taking multiple medications, the period with the longest half-life of those medications was selected. For example, for a patient taking bosentan (half-life < 5 hours) and digoxin (half-life = 33 hours), the drug-free period would be 5 x 33 hours = 165 hours (7 days). After the drug-free period, the medication was prescribed again and continued for 6 months (medicated treatment). The choice of medication was left to the physician's discretion based on a comprehensive analysis. After 6 months, the patient entered a second drug-free period of 5 half-lives to establish PADN as the standard alone treatment.

[0223] For PADN, a 7F flow-directed Swan-Ganz catheter (Edwards, USA) was percutaneously inserted into the internal jugular vein in patients under local anesthesia to measure resting RAP, sRVP, sPAP, mPAP, PAOP, and cardiac output (CO). PVR [=(mPAP-PAOP) / CO] was calculated. All measurements were taken at the end of expiration. If the PAOP measurement was unreliable, left ventricular end-diastolic pressure was measured and used instead of the PAOP measurement. Two blood samples were obtained from the RA, RV, and PA for the measurement of oxygen tension and oxygen saturation. If the difference between the oxygen tension or oxygen saturation measurements of these two samples was >7%, further sampling was performed to identify the location of the left-to-right shunt.

[0224] PADN was performed at three sites around the connection area between the distal main trunk and the ostial left branch. FIG. 23A illustrates an angiogram 2300 of the pulmonary artery in an anterior-posterior and cranial (20°) view. Specifically, the angiogram 2300 illustrates the RPA 2302, MPA 2306, and LPA 2304 of one of the patient's hearts. FIG. 23B illustrates the angiogram of FIG. 23A with a line 2320 representing the lateral wall of the MPA and a line 2318 representing the anterior wall of the LPA. The intersection of these two lines 2312 and 2316 is point 2310. The intersection of the line 2314 representing the posterior wall of the LPA and the line 2320 representing the wall of the MPA is point 2308, which is 1-2 mm posterior to point 2310. Line 2316 starts from the inferior wall of the RPA and ends at point 2310, which is localized at this level and 1-2 mm anterior to point 2310. FIG. 23C illustrates the angiographic image of FIG. 23A, where a catheter with 10 electrodes is positioned at the distal MPA. In FIG. 23C, electrode 2332 corresponds to point 2310, electrode 2330 corresponds to point 2308, and electrode 2334 corresponds to point 2312. The following ablation parameters were programmed for each point: temperature 45° C.-50° C., energy ≦15 W, and time 120 seconds. The procedure was stopped at 10 seconds if the patient experienced unbearable chest pain during the procedure. EKG and pressure lines (including cardiac output) were monitored and recorded continuously throughout the PADN procedure.

[0225] Patients were monitored in the CCU for at least 24 hours. All measurements were repeated at 24 hours, 3 months, 6 months, and 12 months after surgery. Magnetic resonance imaging (MRI) and CT scans of the pulmonary arteries were performed before and 6 months after PADN.

[0226] Successful PADN was defined as a ≥10% reduction in sPAP or mPAP immediately or 24 hours after the procedure compared with baseline values, without any intraoperative complications. The primary endpoint of this additional study was the difference in 6MWD at 6 months between medication and PADN. Secondary endpoints included composite and individual PAH-related events. PAH-related events included worsening of PAH, initiation of intravenous or subcutaneous drug therapy, lung transplantation, atrial septal opening, or death from any cause. Repeated hospitalization was also a secondary endpoint.

[0227] Regarding the assessment of 6MWD, a baseline blood sample was obtained for analysis of N-terminal brain natriuretic peptide (NT-pro BNP) levels before performing the 6MWD. 6MWD, Borg scale, and WHO functional classification class at rest and during exercise were estimated and recorded by a physician blinded to the study design. 6MWD was selected as an end point in previous studies of PAH patients. Notably, 6MWD in patients without PAH-related events was higher than 6MWD in patients with PAH-related events. This suggests that a 15% decrease in 6MWD may be clinically meaningful. This result supports the use of a 15% decrease in 6MWD as a criterion for PAH worsening in clinical studies. In addition, PAP, RAP, and PVR are useful parameters that correlate with the prognosis of PAH patients. sPAP between 50-70 mmHg and RAP>8 mmHg were markers of PAH disease severity. Improvement in 6MWD after PADN was seen along with improvements in RAP, sPAP, and mPAP. However, no correlation between baseline or post-medication PA hemodynamics and 6MWD was established, possibly because improved skeletal blood flow would improve 6MWD even in the absence of changes in PA hemodynamics.

[0228] For echocardiographic measurements, all echocardiograms were performed and interpreted at the Nanjing Echocardiographic Laboratory (Vivid 7, General Electric Co., Easton Turnpike, Connecticut, USA) according to the recommendations of the American Society of Echocardiography. Digital echocardiographic data including at least three consecutive beats (or five beats in the case of atrial fibrillation) were acquired and stored. RV systolic pressure (sRVP) is equal to systolic PAP (sPAP) in the absence of pulmonary stenosis. sPAP is equal to the sum of right atrial (RA) pressure (RAP) and the systolic RV-RA pressure gradient. RAP was estimated based on the echocardiographic features of the inferior vena cava and assigned a standard value. The RV-RA pressure gradient was calculated using a modified Bernoulli equation at 4v t 2 In the formula, v t is the velocity of tricuspid regurgitation in m / s. mPAP was estimated by the velocity of pulmonary regurgitation in m / s. Tricuspid excursion index (Tei) was defined as (AB) / B, where A is the time interval between the end and beginning of the tricuspid annular diastolic velocity and B is the duration of the tricuspid annular systolic velocity (or RV ejection time).

[0229] Table 2 provides data showing how 6MWD increased from 361±112m to 373±111m (p=0.009) after 6 months of medical treatment and from 358±115m to 423±98m (p<0.001) after PADN, along with a significant reduction in NT-pro BNP and WHO functional class. [Table 2]

[0230] Along with significant improvement in hemodynamics after PADN, a significant difference in the increase in 6MWD at 6-month follow-up was found between medication (13±24m) and PADN surgery (65±85m) (95%CI:-21.34 to -3.49, p=0.002). PADN surgery was associated with fewer PAH-related events at 6-month (10.8%) and 12-month (17.9%) follow-up compared with 42.9% after 6-month medication treatment (all p<0.05). As illustrated in Table 3 and Figure 24A, Δ6MWD (defined as 6MWD at 6-month follow-up minus baseline 6MWD) was +13±24m (+3.9% increase) in medication treatment. This was very different from +65±85m (+23.9% increase, 95% CI: -21.34 to -3.49, p=0.002) at 6 months after PADN and +95±61m (+34.9% increase) at 1 year after PADN. [Table 3]

[0231] In the medical treatment, 9 patients (32%) had a decrease in 6MWD (range: -6m to -47m) after 6 months of treatment. Of these 9 patients, 5 patients had a mean 6MWD increase of 45m at 6 months after PADN surgery, while 4 patients showed no change. One of these 4 patients showed no change in 6MWD even at 1 year after PADN surgery. Finally, there were 2 patients who showed no change in 6MWD at 1 year follow-up after PADN surgery. As illustrated in Figure 24B, 6MWD after PADN surgery rather than after medical treatment had a negative correlation with mPAP (r=-0.416, p=0.028) and sPAP (r=-0.401, p=0.034).

[0232] This study also demonstrated improved hemodynamics and cardiac function. ΔmPAP and ΔCO at 6 months after PADN were higher than those in the drug-treated setting (-7.86 ± 6.10 mmHg vs. -0.14 ± 2.48 mmHg, P < 0.001; 0.67 ± 1.05 L / min / 1.73 m2 0.06±0.24L / min / 1.73m 2 , p = 0.005, Table 3), and as a result, there was a significant difference in the reduction of pericardial fluid volume (-0.74 ± 2.63 mm vs. +0.11 ± 0.93 mm, p = 0.036) and Tei (-0.34 ± 0.11 points vs. -0.04 ± 0.09 points, p < 0.001). As illustrated in Figure 24C, these improvements were maintained through the 1-year follow-up after PADN surgery.

[0233] Table 4 shows how, after 6 months of treatment, PAH-related events were observed in 12 patients (42.9%) in medical treatment and in 3 patients (10.8%) in PADN surgery (p=0.002). These events were mainly due to the worsening of PAH. [Table 4]

[0234] The mean time from treatment to clinical deterioration was 125 days (range 22-166 days) for medical treatment. This was significantly shorter than the reported 166 days (range 47-172 days) for PADN (p=0.01). Readmission was required in 42.9% of patients for medical treatment compared with 14.4% for PADN (p=0.018 in Table 4). After 6 months of treatment, there were no access hematomas, aneurysms, thrombus formation, or death from any cause.

[0235] Δ6MWD was approximately +60m after PADN and +15m after medical treatment. A total of 28 patients were required to achieve significance (two-sided p-value, 80% power). Differences (6-month period minus baseline) in each variable for each treatment were calculated and compared between the two treatments. Continuous variables were expressed as mean ± SD. Normality tests for all continuous variables were performed using the Kolmogorov-Smirnov test and the Shapiro-Wilk test. Differences in continuous variables between the two treatments were analyzed using paired t-tests or Mann-Whitney U-tests when appropriate. Categorical variables were compared using Fisher's exact test. Recurrence-free survival rates were generated using the Kaplan-Meier method and analyzed using the log-rank test. Statistical significance was defined as a two-sided P-value <0.05. All analyses were performed using the statistical program SPSS 19.0 (SPSS Institute Inc., Chicago, IL, USA).

[0236] For this additional study, worsening of PAH was defined as the occurrence of all three of the following observations: a decline in 6MWD from baseline of at least 15% confirmed by a second 6MWD performed on a different day within 14 days of the first measurement; worsening of PAH symptoms; and need for further treatment for PAH. Worsening of PAH symptoms was defined as any of the following observations: a change from baseline to a higher WHO functional class (or no change in patients with a baseline WHO functional class IV); and emergence or worsening of signs of right heart failure unresponsive to oral diuretic therapy. An independent clinical events committee adjudicated in a blinded manner all events related to PAH and all deaths reported by the end of treatment.

[0237] At 1-year follow-up, there were 5 (17.9%) PAH-related events (2 new events including 2 sudden deaths). The 6MWD in patients without PAH-related events was 467 ± 100 m, which was higher than the 393 ± 42 m reported in patients who experienced an event (p = 0.018). Thus, patients with a 6MWD < 400 m had a higher rate of PAH-related events (44.4%) at 1 year after PADN compared with a PAH-related event rate of 5.3% in patients with a 6MWD ≥ 400 m (p = 0.010).

[0238] Thus, this additional study demonstrated that PADN procedure was associated with significant improvements in 6MWD and hemodynamics at 6 months and fewer PAH-related events. For example, PADN procedure significantly improved pulmonary artery hemodynamics and was associated with lower rates of subsequent PAH-related events and rehospitalizations.

[0239] Figures 25A-25H are various views of a digital ablation controller 2500 that may be used in place of the controller 100 illustrated in Figures 15C-15D. Similar to controller 100, digital ablation controller 2500 may be connected to a catheter handle 2 to provide ablation energy. For example, digital ablation controller 2500 may be configured to provide ablation energy and control electrodes E1-E10 of Figure 15B.

[0240] In summary, the digital ablation controller 2500 provides a single portable housing for both control and feedback during the performance of a PADN procedure. The digital ablation controller 2500 may control the amount of power provided from a power source (e.g., a battery or a power grid) to the electrodes 5 such that the amount of power is within nominal limits for ablation. The digital ablation controller 2500 may also allow for the storage and retrieval of various patient profiles, which may include different configuration settings for the catheter configuration and / or the provision of power to the electrodes of the catheter.

[0241] For example, different patient profiles may include different settings for performing PADN procedures with different settings for different electrodes. Digital ablation controller 2500 may also include a user interface through which a user or operator of the digital ablation controller may manually operate controls and / or input or retrieve information from the patient profile.

[0242] For example, the user interface may include information about the operating characteristics of the electrodes (e.g., ablation temperature and time obtained by sensors in the catheter), and the user or operator of the digital ablation controller may perform the PADN procedure based on the operating characteristics of the electrodes. The user or operator of the digital ablation controller may also directly select a particular electrode (or electrodes) to activate for ablation from the user interface, and the digital ablation controller will then direct power (e.g., power from a battery) to the appropriate electrode(s) selected via the user interface.

[0243] In certain embodiments, the digital ablation controller may provide automatic control of the PADN procedure based on feedback from sensors on the catheter. For example, the operating characteristics of the electrodes may be obtained by the catheter sensors and used to control aspects of the PADN procedure (e.g., the time to perform ablation at a particular location based on the temperature at that location).

[0244] In certain embodiments, the digital ablation controller includes a battery configured to store power to a sufficient level for ablation using one or more electrodes 5 of a multipolar simultaneous pulmonary artery radiofrequency ablation catheter. By using the battery directly, the electrodes are powered by stored power rather than power provided to the electrodes on an ad-hoc basis, such as by power provided by a local power grid. This allows the digital ablation controller to function without reliance on the local power grid as long as the battery is sufficiently charged, rather than power being available as power becomes available to the digital ablation controller.

[0245] FIG. 25A illustrates a top perspective view of the digital ablation controller 2500 in a closed position. This top perspective view illustrates a power cord 2504 connected to the digital ablation controller 2500. As illustrated, the digital ablation controller 2500 may be a single housing configured to provide an interface for control and power of a multi-polar simultaneous pulmonary artery radiofrequency ablation catheter. For example, the digital ablation controller 2500 may receive and store power so that a PADN procedure can be performed using stored (battery) power in the digital ablation controller 2500. The digital ablation controller 2500 may also provide precise power control by digitally controlling various aspects of the PADN procedure, such as the specific electrode(s) used for ablation, the power at the specific electrodes, and the duration of the ablation. The digital ablation controller 2500 may also provide real-time feedback from sensors (e.g., temperature sensors and / or impedance sensors) placed at various points (such as at the electrode locations) on the multipolar simultaneous pulmonary artery radiofrequency ablation catheter as described in Figures 1-4.

[0246] Figure 25B illustrates a top perspective view of the digital ablation controller 2500 in the open position. A user interface 2512 is visible and usable in the open position of the digital ablation controller 2500. A handle 2510 is also illustrated on the digital ablation controller 2500. Figure 25C illustrates a rear perspective view of the digital ablation controller 2500 in the open position.

[0247] 25D is a screenshot of an initial user interface 2526 of the digital ablation controller 2500. The initial user interface includes buttons that can be selected to interact with the digital ablation controller 2500. For example, the initial user interface 2526 illustrates a button 2520 for changing the language setting of the user interface, a button 2522 for accessing data stored in the digital ablation controller 2500, and a button 2524 for initiating operation of the digital ablation controller 2500.

[0248] 25E is a screenshot of a user interface 2530 presenting options for entering patient information for performing a PADN procedure. The user interface includes a button 2532 for initiating a browse of existing patient profiles stored in the digital ablation controller 2500. The user interface also includes a section 2534 for entering information for a new patient profile, including the patient's name, identification number, age, sex, and various pre-set operating setting selections for the digital ablation controller 2500. The user interface also includes a section 2536 for entering notes about the patient for that patient profile.

[0249] 25F is a screenshot of the user interface 2540 of the digital ablation controller 2500 at the start of a PADN procedure. The user interface 2540 includes information regarding power level 2542, time 2544, temperature 2546, and catheter electrode impedance 2548. The user interface also includes buttons that allow a particular electrode 5 on the annular ring 4 to be selected for activation.

[0250] FIG. 25G is a screenshot of the user interface 2550 of the digital ablation controller 2500 in operation. Ablation may be initiated by selecting a button for a particular electrode, such as button 2570 associated with electrode 2572, indicated by a highlighted number "2" on the user interface. The operational relationship of impedance, power, and temperature of electrode 2572 over time is shown on graph 2552. In the illustrated embodiment, a single electrode is selected in the user interface and used for ablation, although in certain embodiments, multiple electrodes are selected and used simultaneously for ablation. Ablation may also be interrupted while switching between electrodes used for ablation. Switching between different electrodes for ablation may be performed in any manner, such as digital-analog / solid-state switching, that allows the energy used for ablation to be directed to the various electrodes of the multipolar simultaneous pulmonary artery radiofrequency ablation catheter.

[0251] 25H is a screenshot 2580 of the user interface of the digital ablation controller 2500 presenting information regarding saved patient profiles. The user interface shows that there are two patient profiles 2582, 2584 that may be selected. Each patient profile shows a name 2586, a patient identification number 2588, and a time of last access 2590 to the saved patient profile. The user interface also includes a button 2592 for exporting the various patient profiles and an option button 2594 for deleting the selected patient profile.

[0252] FIG. 26 is a schematic diagram illustrating a mechanical switching system 2600 that may be implemented in the controller 2500 of FIGS. 25A-25H or the controller 100 of FIGS. 15C-15D. The mechanical switching system 2600 includes a source contact 2602, a mechanical switch 2604, electrode contacts 2606A-J, and a ground contact 2610. The source contact 2602 may be connected to a source of RF energy at a level sufficient for ablation. The electrode contacts 2606A-J may each be connected to a different electrode 2608A-J that may be used for ablation. The ground contact 2610 may be connected to a ground 2612. The electrodes 2608A-J may be located at a distal end of the catheter. The mechanical switch 2604 may be actuated as part of a dial or knob 2612 that may be physically moved, such that the mechanical switch 2604 connects the source contact 2602 to a particular electrode contact 2606A-J or the ground contact 2610. For example, the mechanical switch 2604 may be actuated by being physically moved in a clockwise or counterclockwise direction. In the illustrated embodiment, the switch 2604 is positioned to connect the source contact 2602 to the electrode contact 2606A.

[0253] FIG. 27 is a schematic diagram illustrating a solid-state switching system 2700 that may be implemented in the controller 2500 of FIGS. 25A-25H or the controller 100 of FIGS. 15C-15D. In contrast to the mechanical switching system 2600 of FIG. 26, the solid-state switching system 2700 is operated without the use of any physically moving moving parts. The solid-state switching system 2700 may include a source contact 2602, a selector contact 2702 connected to a signal source, solid-state switches 2704A-J, electrode contacts 2606A-J, and a ground 2612. The electrode contacts 2606A-J are each connected to a different electrode 2608A-J that may be used for ablation. The source contact 2602 may be connected to a source of RF energy at a level sufficient for ablation. The solid-state switching system may set the selector contact 2702 to a particular signal (e.g., to a particular voltage level) that causes a particular solid-state switch 2704A-J to connect the source contact 2602 to a particular electrode contact 2606A-J. For example, the solid-state switching system may set the selector contact 2702 to a voltage level that activates the solid-state switch 2704J to connect the source contact 2602 to the electrode contact 2606J, thereby providing a sufficient level of RF energy for ablation to the electrode associated with the electrode contact 2606J. Also, with the solid-state switch 2704J connecting the source contact 2602 to the electrode contact 2606J, the other solid-state switches 2704A-I may maintain a connection between their associated electrode contacts 2606A-I and ground 2612. The solid-state switches may be implemented using any type of solid-state device, including MOSFETs, IGBTs, bipolar transistors, and thyristors.

[0254] Figure 28 illustrates a generic switching system 2800 that may be implemented in the controller 2500 of Figures 25A-25H or the controller 100 of Figures 15C-15D. The generic switching system 2800 may implement any type of switching system to connect the source contacts 2602 to particular electrode contacts 2606A-J. For example, the generic switching system may be implemented using mechanical switches, solid-state switches, or a combination of mechanical and solid-state switches.

[0255] As used herein, the term "animal" is intended to include humans, other animals such as dogs, other mammals, etc. As used herein, the terms "live," "living," and "live animal" are intended to exclude methods of euthanasia, surgery performed on dead animals, including dissections and necropsies, or other procedures for disposing of the body.

[0256] At least several different embodiments are disclosed herein, but it should be understood that many variations exist. The embodiments described herein are not intended to limit the scope, scope, or configuration of the claimed subject matter in any way. Rather, the above detailed description will provide those skilled in the art with a convenient guide for implementing the described embodiments. It should be understood that various changes may be made in the function and arrangement of elements or steps without departing from the scope defined by the claims, including equivalents known and foreseeable equivalents at the time of filing this patent.

Claims

1. 1. An apparatus for ablating target tissue in a main pulmonary artery of a patient, comprising: a catheter body having a proximal end and a terminal distal end; an annular ring coupled to the distal terminal end of the catheter body; a plurality of electrodes supported by the annular ring; Equipped with the target tissue includes a left lateral apex of the main pulmonary artery, an anterior side of the left lateral apex, and a posterior side of the left lateral apex; the plurality of electrodes comprising a first electrode positioned and sized to contact the left lateral apex end of the main pulmonary artery when the annular ring is positioned within the main pulmonary artery, a second electrode positioned and sized to contact an anterior side of the left lateral apex end, and a third electrode positioned and sized to contact a posterior side of the left lateral apex end; Only the first electrode, the second electrode, and the third electrode are disposed in the annular ring; the first electrode, the second electrode, and the third electrode are disposed on a half circumference of the annular ring; Device.

2. The device of claim 1 , wherein the second electrode and the third electrode of the plurality of electrodes are positioned on the annular ring straddling either side of the first electrode.

3. 2. The device of claim 1, wherein the distal terminal end of the catheter body is flexible and the annular ring is perpendicular to the distal terminal end when positioned in the main pulmonary artery.

4. The apparatus of claim 1 , wherein the annular ring is planar.

5. The apparatus of claim 1 , wherein the annular ring comprises a curve of less than 360 degrees.

6. 2. The device of claim 1, wherein the first electrode has a first length, the second electrode has a second length different from the first length, and the third electrode has a third length different from the first length and different from the second length.

7. The apparatus of claim 1 , wherein the first, second, and third electrodes are substantially coplanar.

8. The apparatus of claim 1 , wherein the annular ring comprises a curve that is less than 360 degrees and greater than 270 degrees.

9. The device of claim 6 , wherein the first length is 4 mm.

10. 7. The device of claim 6, wherein the second length is at least 3 mm and less than the first length.

11. 7. The device of claim 6, wherein the third length is at least 2 mm and less than the second length.

12. The apparatus of claim 1 , wherein the first electrode is spaced equal distances from the second electrode and the third electrode.

13. The device is connected to an ablation controller configured to direct a first amount of electrical power to the first electrode and a second amount of electrical power to the second electrode or the third electrode; The apparatus of claim 1 , wherein the first amount of power is different from the second amount of power.

14. The apparatus of claim 1 , further comprising a plurality of sensors coupled to the plurality of electrodes for acquiring sensor data including one or more tissue properties.

15. The apparatus of claim 14, wherein the apparatus is connected to an ablation controller configured to determine the times when ablation is performed at the left lateral apex of the main pulmonary artery, anterior to the left lateral apex, and posterior to the left lateral apex based on the sensor data.

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