Automated performance of irreversible electroporation ablation during cardiac refractory periods

Abstract

To provide methods and systems for improving patient safety in irreversible electroporation ablation procedures.SOLUTION: A method includes inserting an ablation catheter into an ablation site in a patient heart. Multiple electrocardiogram (ECG) signals are acquired. A refractory period of the patient heart is detected based on the acquired ECG signals. The ablation site is ablated using the ablation catheter during the detected refractory period.SELECTED DRAWING: Figure 1

Description

[Technical Field]

[0001] The present invention relates generally to tissue ablation, and more particularly to methods and systems for improving patient safety in irreversible electroporation ablation procedures. [Background technology]

[0002] Various techniques are known in the art for ablating cardiac tissue by applying irreversible electroporation (IRE) pulses.

[0003] For example, U.S. Patent No. 10,531,914 describes a method for ablating tissue by applying at least one pulse train of pulsed field energy, the method including delivering a pulse train of energy having a predetermined frequency to cardiac tissue.

[0004] U.S. Patent No. 10,322,286 describes a system including a pulse waveform generator and an ablation device coupled to the pulse waveform generator. The ablation device includes at least one electrode configured for ablation pulse delivery to tissue during use. The pulse waveform generator is configured to supply voltage pulses to the ablation device in the form of a pulse waveform. Summary of the Invention [Means for solving the problem]

[0005] One embodiment of the present invention described herein provides a method that includes inserting an ablation catheter into an ablation site within a patient's heart. A plurality of electrocardiogram (ECG) signals are acquired using the catheter. A refractory period of the patient's heart is detected based on the acquired ECG signals. The ablation site is ablated using the ablation catheter during the detected refractory period.

[0006] In some embodiments, acquiring the plurality of ECG signals includes acquiring at least one of (i) an intracardiac (IC) ECG signal at the ablation site, and (ii) a body surface (BS) ECG signal, hi other embodiments, detecting the refractory period includes indicating sinus rhythm in at least one of the acquired ECG signals.

[0007] In one embodiment, ablating the ablation site includes applying one or more irreversible electroporation (IRE) pulses to tissue at the ablation site during the detected refractory period. In another embodiment, applying the one or more IRE pulses includes controlling an IRE pulse generator and applying the IRE pulses to tissue in response to receiving at least one of an ECG signal indicative of sinus rhythm.

[0008] There is also provided, in accordance with an embodiment of the present invention, a system including a plurality of surface electrodes and a processor, wherein the one or more electrodes are configured to sense a plurality of electrocardiogram (ECG) signals of a patient's heart, and the processor is configured to detect a refractory period of the patient's heart based on the acquired ECG signals and control ablation at the ablation site during the detected refractory period.

[0009] In some embodiments, the electrodes include (i) at least a first electrode attached to the catheter and configured to sense intracardiac (IC) ECG signals at the ablation site, and (ii) a second electrode coupled to the patient's surface and configured to sense body surface (BS) ECG signals of the patient's heart. In other embodiments, the processor is configured to detect a refractory period based on at least one of the ECG signals indicative of a sinus rhythm pulse. In yet other embodiments, the system includes an irreversible electroporation (IRE) pulse generator configured to apply an IRE pulse to tissue at the ablation site during the detected refractory period.

[0010] In one embodiment, the IRE pulse generator is configured to apply one or more bipolar IRE pulses between a pair of electrodes in contact with tissue at the ablation site. In another embodiment, at least one of the one or more electrodes is attached to the catheter and configured to at least one of: (i) sense intracardiac ECG signals at the ablation site; and (ii) apply one or more irreversible electroporation (IRE) pulses to tissue at the ablation site.

[0011] According to one embodiment of the present invention, there is further provided a system including: (i) an interface configured to receive a plurality of electrocardiogram (ECG) signals of a patient's heart; and (ii) a processor configured to detect a refractory period of the patient's heart based on the received ECG signals, and to control ablation at the ablation site during the detected refractory period. [Brief explanation of the drawings]

[0012] The present invention will be more fully understood from the following detailed description taken in conjunction with the drawings, in which: [Figure 1] 1 is a schematic, pictorial illustration of a catheter-based position tracking and irreversible electroporation (IRE) ablation system, in accordance with an exemplary embodiment of the present invention; [Figure 2] 1 is a flow chart that schematically illustrates a method for automatically performing IRE ablation during cardiac refractory periods, in accordance with an exemplary embodiment of the present invention. DETAILED DESCRIPTION OF THE INVENTION

[0013] Overview Irreversible electroporation (IRE) can be used, for example, to treat arrhythmias by ablating tissue cells using high-voltage applied pulses. Cell destruction occurs when the transmembrane potential exceeds a threshold, resulting in cell death and lesion formation. In an IRE-based ablation procedure, for example, a high-voltage bipolar electrical pulse is applied to a pair of electrodes in contact with the tissue to be ablated, forming a lesion between the electrodes, thereby treating the arrhythmia in the patient's heart.

[0014] The rhythm of a patient's heart is determined, inter alia, by electrical activation pulses initiated by the sinus node of the heart. Therefore, applying an IRE pulse and an activation pulse simultaneously can be harmful to the patient because it can interfere with the heart rhythm.

[0015] The embodiments of the present invention described below provide improved techniques for applying one or more IRE pulses during the refractory period between sinus node electrical activation pulses.

[0016] In some embodiments, a physician inserts an ablation catheter into an ablation site within the patient's heart that contains tissue intended to be ablated, the ablation catheter comprising at least a pair of electrodes in contact with the cardiac tissue at the ablation site.

[0017] The pair of electrodes (also referred to herein as the first electrode) is configured to acquire intracardiac (IC) electrocardiogram (ECG) signals at the ablation site of the patient's heart and to apply bipolar IRE pulses to cardiac tissue located between the two electrodes of the pair.

[0018] In some embodiments, a second set of multiple electrodes is coupled, for example to the patient's skin, to acquire body surface (BS) ECG signals from the patient's heart.

[0019] In some embodiments, the processor is configured to receive both IC and BS ECG signals and check whether one or more of the acquired ECG signals are in sinus node rhythm. In response to identifying one or more IC and / or BS ECG signals in sinus node rhythm, the processor is configured to detect a refractory period of the patient's heart and control an IRE pulse generator (IPG) to apply one or more IRE pulses (via at least one pair of first electrodes) to the ablation site during the detected refractory period. While the entire process described above is performed automatically, e.g., without intervention by a physician, it should be noted that a physician may have the means to intervene to adjust or ablate the IRE ablation procedure, if desired.

[0020] The disclosed techniques improve the quality and safety of tissue ablation by preventing the application of an IRE pulse to tissue at the same time that the sinus node applies an activation pulse, and by ensuring that the IRE pulse is applied to tissue at the ablation site during its refractory period. Additionally, the disclosed techniques remove some of the burden associated with performing an IRE procedure from the physician and allow for monitoring the quality of the IRE procedure.

[0021] System Description FIG. 1 is a schematic, pictorial illustration of a catheter-based position tracking and irreversible electroporation (IRE) ablation system 20, in accordance with an embodiment of the present invention.

[0022] Referring now to inset 25, in some embodiments, system 20 comprises a deflectable tip section 40 mounted on the distal end 22a of shaft 22 of catheter 21, the deflectable tip section 40 including a plurality of electrodes 50.

[0023] In the embodiments described herein, the electrodes 50 are configured to sense intracardiac (IC) electrocardiogram (ECG) signals and may be used in addition to IRE ablation of tissue in the left atrium of the heart 26, such as IRE ablation of the ostia 51 of the pulmonary veins (PV) within the heart 26. It should be noted that the techniques disclosed herein are applicable, mutatis mutandis, to other portions of the heart 26 (e.g., the atria or ventricles) and other organs of the patient 28.

[0024] Referring again to the overall view of Figure 1, in some embodiments, the proximal end of catheter 21 is connected to a control console 24 (also referred to herein as console 24 for brevity) that includes an ablation power source, in this example an IRE pulse generator (IPG) 45 configured to deliver peak power in the range of tens of kilowatts (kWs). Console 24 includes a switching box 46 configured to switch the power applied by IPG 45 to one or more selected pairs of electrodes 50. The sequenced IRE ablation protocol may be stored in memory 48 of console 24.

[0025] In some embodiments, physician 30 inserts distal end 22 a of shaft 22 through sheath 23 into heart 26 of patient 28 lying on table 29. Physician 30 guides distal end 22 a of shaft 22 to a target location within heart 26 by manipulating shaft 22 using manipulator 32 located near the proximal end of catheter 21. During insertion of distal end 22 a, deflectable tip section 40 is maintained in a straight configuration by sheath 23. By housing tip section 40 in a straight configuration, sheath 23 also serves to minimize vascular trauma as physician 30 navigates catheter 21 through the vasculature of patient 28 to a target location, such as an ablation site, within heart 26.

[0026] Once the distal end 22a of the shaft 22 reaches the ablation site, the physician 30 retracts the sheath 23, deflects the tip section 40, and further manipulates the shaft 22 to position the electrode 50 disposed on the tip section 40 into contact with the ostium 51 of the ablation site. In this example, the ablation site includes one or more PVs of the heart 26, although in other embodiments, the physician 30 may select any other suitable ablation site.

[0027] In some embodiments, the electrodes 50 are connected by wires that extend through the shaft 22 to a processor 41 that is configured to control a switching box 46 using an interface circuit 44 in the console 24 .

[0028] As further shown in inset 25, distal end 22a includes a position sensor 39 of a position tracking system, which is coupled to distal end 22a, for example, at tip portion 40. In this example, position sensor 39 includes a magnetic position sensor, although in other embodiments, any other suitable type of position sensor (e.g., other than magnetic-based) may be used. During navigation of distal end 22a within heart 26, processor 41 receives signals from magnetic position sensor 39 in response to magnetic fields from external magnetic field generator 36, for example, to measure the position of tip portion 40 within heart 26 and, optionally, to present the tracked position superimposed on an image of heart 26 on display 27 of console 24. Magnetic field generator 36 is positioned at a known location outside patient 28, for example, beneath patient table 29. Console 24 also includes a driver circuit 34 configured to drive magnetic field generator 36.

[0029] This method of position sensing using external magnetic fields has been implemented in various medical applications, for example, in the CARTO™ system manufactured by Biosense Webster Inc. (Irvine, California), and is described in detail in U.S. Pat. Nos. 5,391,199, 6,690,963, 6,484,118, 6,239,724, 6,618,612, and 6,332,089, WO 96 / 05768, and U.S. Patent Application Publication Nos. 2002 / 0065455(A1), 2003 / 0120150(A1), and 2004 / 0068178(A1), the disclosures of which are all incorporated herein by reference.

[0030] Processor 41 of console 24 includes processor 41, typically a general-purpose processor of a general-purpose computer, with suitable front-end and interface circuitry 44 for receiving signals from catheter 21 and administering ablation energy via catheter 21 in the left atrium of heart 26, as well as controlling other components of system 20. Processor 41 typically includes software in memory 48 of system 20 that is programmed to perform the functions described herein. The software may be downloaded in electronic form to the computer, for example, over a network, or alternatively or additionally, may be provided and / or stored on a non-transitory, tangible medium, such as magnetic, optical, or electronic memory.

[0031] Perform irreversible electroporation ablation during the cardiac refractory period Irreversible electroporation (IRE), also known as pulsed field ablation (PFA), can be used as a minimally invasive treatment modality to kill tissue cells at the ablation site by applying high-voltage pulses to tissue. In this example, IRE pulses may be used to kill myocardial tissue cells to treat cardiac arrhythmias within the heart 26. Cell destruction occurs when the transmembrane potential exceeds a threshold, resulting in cell death and, therefore, the development of a tissue lesion. Therefore, of particular interest is the use of high-voltage bipolar electrical pulses, e.g., using a pair of electrodes 50 in contact with the tissue at the ablation site to generate a high electric field (e.g., above a certain threshold) to kill tissue cells located between the electrodes.

[0032] In the context of this disclosure, a "bipolar" voltage pulse means a voltage pulse applied between two electrodes 50 of the catheter 21 (as opposed to a monopolar pulse applied by the catheter electrodes relative to some common ground electrode not located on the catheter, e.g., during radiofrequency ablation).

[0033] To perform IRE ablation over a relatively large tissue region of the heart 26, such as around the ostia of a pulmonary vein (PV) or any other suitable organ, it is necessary to use multiple pairs of electrodes 50 of a catheter 21 having multiple electrodes 50 within a deflectable tip section 40. To make the generated electric field as spatially uniform as possible over a large tissue region, it is best to have pairs of electrodes 50 selected with overlapping fields, or at least magnetic fields adjacent to each other. However, there is a Joule heating component that occurs in the IRE-generated field, and this heating can damage the electrodes if multiple pairs of electrodes 50 are used sequentially to deliver a sequence of IRE pulses.

[0034] In one embodiment, system 20 includes surface electrodes 38, shown in the example of FIG. 1, attached by wires extending through cable 37 to the chest and shoulders of patient 28. In some embodiments, surface electrodes 38 are configured to sense body surface (BS) ECG signals in response to the beating of heart 26. Acquisition of BS ECG signals may be performed using conductive pads attached to the body surface or any other suitable technique. Any pair of electrodes 38 can measure the potential difference between two corresponding points of attachment. Such pairs form leads. However, "leads" may also be formed between a physical electrode known as a Wilson central terminal and a virtual electrode. For example, ten body-attached electrodes 38 may be used to form 12 ECG leads, with each lead measuring a specific potential difference within heart 26. As shown in FIG. 1, surface electrodes 38 are attached to the chest and shoulders of patient 28, although additional surface electrodes 38 may be attached to other organs of patient 28, such as the limbs. In the context of this disclosure and claims, the potential difference measured between the surface electrodes 38 is referred to herein as the body surface (BS) ECG signal.

[0035] In the heart 26, sinus rhythm is any cardiac rhythm in which depolarization of the myocardium begins at the sinus node. Sinus rhythm is characterized by the presence of a precisely oriented P wave on the ECG. Sinus rhythm is necessary, but not sufficient, for normal electrical activity within the heart. After an action potential is initiated (e.g., by the sinus node), cardiac cells of the heart 26 are unable to initiate another action potential for a period of time. This period, which is approximately 250 ms in duration, is referred to herein as the refractory period, which helps protect the heart.

[0036] In some embodiments, electrodes 50 are configured to sense the aforementioned IC ECG signals, and (eg, simultaneously) surface electrodes 38 sense BS ECG signals.

[0037] In some embodiments, processor 41 is configured to receive body surface (BS) ECG signals from surface electrodes 38 and intracardiac (IC) ECG signals from electrodes 38. Processor 41 is further configured to check whether either the IC ECG signal or the BS ECG signal is in sinus node rhythm.

[0038] In some embodiments, if none of the acquired ECG signals are in sinus node rhythm, the processor 41 continues to receive and analyze additional IC and BS ECG signals over time.

[0039] In some embodiments, based on the acquired BS and IC ECG signals, in response to the ECG signal being in sinus node rhythm, processor 41 is configured to detect a refractory period of heart 26. Note that for safety reasons, application of an IRE pulse is permitted during the refractory period, but not at the initiation of an action potential.

[0040] In some embodiments, processor 41 is configured to control IPG 45 to apply one or more IRE pulses to tissue at the ablation site of heart 26 via one or more pairs of electrodes 50 selected by switch box 46. For example, physician 30 may send a command to processor 21 to activate IPG 45 (or may directly activate the controller of IPG 45), e.g., by pressing a foot pedal. Processor 41 is configured to receive IC and BS ECG signals from electrodes 50 and 38, respectively, and to control IPG 45 to apply IRE pulses at the detected refractory period when at least one of the IC and / or BS ECG signals indicates sinus rhythm. In other words, upon detecting a refractory period of heart 26, processor 41 controls IPG 45 to apply IRE pulses to tissue at the ablation site of heart 26.

[0041] In some embodiments, processor 41 is configured to automatically perform the IRE ablation procedure. In such embodiments, processor 41 is configured to control (i) the number and quality of IC and BS ECG signals acquired from heart 26, (ii) the timing of application of IRE pulses to tissue 9 during one or more refractory periods, and (iii) at least some parameters of the applied IRE pulses. Note that after positioning at least one pair of electrodes 50 in contact with tissue at the ablation site, physician 30 may instruct processor 41 to automatically control the acquisition of ECG signals and the application of IRE pulses. However, if needed (e.g., in an emergency), physician 30 may intervene in the IRE procedure by, for example, adjusting and / or halting processes performed by processor 41.

[0042] FIG. 2 is a flow chart that schematically illustrates a method for automatically performing IRE ablation during the refractory period of heart 26, in accordance with an embodiment of the present invention.

[0043] The method begins with a catheter insertion step 100 in which a physician inserts a catheter 21 using a position tracking system to position one or more pairs of electrodes 50 attached to the ablation site of the heart 26, as described above in FIG. 1 .

[0044] In an ECG signal acquisition step 102, the processor 41 is configured to receive intracardiac (IC) and body surface (BS) ECG signals from the electrodes 50 and 38, respectively, as described in FIG. 1 above.

[0045] In sinus rhythm detection step 104, processor 41 is configured to check whether one or more IC and / or BS ECG signals are in sinus node rhythm. If no ECG signals are in sinus node rhythm, the method loops back to step 102, where processor 41 continues to check additional IC and BS ECG signals acquired by electrodes 50 and 38, respectively. If the processor identifies an IC and / or BS ECG signal in sinus node rhythm, the method continues to IRE ablation step 106, which ends the method.

[0046] In an IRE ablation step 106 based on IC and / or BS ECG signals in sinus node rhythm, processor 41 is configured to (i) detect a refractory period of the patient's heart and (ii) control IPG 45 to apply an IRE pulse to ablate tissue at an ablation site in heart 26 during the detected refractory period. Note that the IRE pulse is applied to the tissue via one or more pairs of electrodes 50 selected by switch box 46 or using any other suitable selection mechanism.

[0047] The method described in FIG. 2 may be performed automatically, for example, without intervention by a physician 30, although the physician 30 may have the means to intervene, if necessary, to adjust or abort the above-described automatic IRE ablation procedure.

[0048] Although the embodiments described herein are primarily directed to IRE ablation of cardiac tissue, the methods and systems described herein may be used in other applications, such as ablating other organs in humans or other mammals.

[0049] It will therefore be understood that the above-described embodiments are cited by way of example, and that the present invention is not limited to what has been particularly shown and described above. Rather, the scope of the present invention includes both combinations and subcombinations of the various features described in the foregoing specification, as well as variations and modifications thereof that would occur to one skilled in the art upon reading the foregoing description, and that are not disclosed in the prior art. Documents incorporated by reference into this patent application are to be deemed part of this application, except that if any term is defined in such incorporated document in a way that contradicts the definition given herein, either expressly or impliedly, then only the definition given herein shall be considered.

[0050] [Embodiment] (1) A method for performing irreversible electroporation during a cardiac refractory period, comprising: inserting an ablation catheter into an ablation site within the patient's heart; acquiring a plurality of electrocardiogram (ECG) signals; detecting a refractory period of the patient's heart based on the acquired ECG signal; ablating the ablation site using the ablation catheter during the detected refractory period. (2) The method of embodiment 1, wherein acquiring the plurality of ECG signals includes acquiring at least one of (i) an intracardiac (IC) ECG signal at the ablation site, and (ii) a body surface (BS) ECG signal. (3) The method of embodiment 1, wherein detecting the refractory period includes exhibiting sinus rhythm in at least one of the acquired ECG signals. (4) The method of embodiment 1, wherein ablating the ablation site comprises applying one or more irreversible electroporation (IRE) pulses to tissue at the ablation site during the detected refractory period. (5) The method of embodiment 4, wherein applying the one or more IRE pulses includes controlling an IRE pulse generator and applying the IRE pulses to the tissue in response to receiving at least one of the ECG signals indicative of the sinus rhythm.

[0051] (6) A system for performing irreversible electroporation during cardiac refractory periods, comprising: one or more electrodes configured to sense a plurality of electrocardiogram (ECG) signals of the patient's heart; a processor configured to detect a refractory period of the patient's heart based on the acquired ECG signal, and to control ablation at the ablation site during the detected refractory period. (7) The system of embodiment 6, wherein the electrodes include (i) at least a first electrode attached to a catheter and configured to sense an intracardiac (IC) ECG signal at the ablation site, and (ii) a second electrode coupled to the surface of the patient and configured to sense a body surface (BS) ECG signal of the patient's heart. (8) The system of embodiment 6, wherein the processor is configured to detect the refractory period based on at least one of the ECG signals indicative of a sinus rhythm pulse. (9) The system described in embodiment 6, comprising an irreversible electroporation (IRE) pulse generator configured to apply an IRE pulse to tissue at the ablation site during the detected refractory period. (10) The system of embodiment 9, wherein the processor is configured to control the IRE pulse generator to apply the IRE pulse in response to receiving at least one of the ECG signals indicating a sinus rhythm pulse.

[0052] (11) The system of embodiment 9, wherein the IRE pulse generator is configured to apply one or more bipolar IRE pulses between a pair of the electrodes in contact with tissue at the ablation site. (12) The system of embodiment 6, wherein at least one of the one or more electrodes is attached to a catheter and configured to perform at least one of: (i) sensing intracardiac ECG signals at the ablation site; and (ii) applying one or more irreversible electroporation (IRE) pulses to tissue at the ablation site. (13) A system for performing irreversible electroporation during a cardiac refractory period, comprising: an interface configured to receive a plurality of electrocardiogram (ECG) signals of the patient's heart; a processor configured to detect a refractory period of the patient's heart based on the received ECG signal and to control ablation at the ablation site during the detected refractory period. (14) The system of embodiment 13, wherein the interface is configured to receive at least one of (i) an intracardiac (IC) ECG signal at the ablation site, and (ii) a body surface (BS) ECG signal. (15) The system of embodiment 13, wherein the processor is configured to detect the refractory period by indicating sinus rhythm in at least one of the received ECG signals.

[0053] (16) The system described in embodiment 13, comprising an irreversible electroporation (IRE) pulse generator configured to apply an IRE pulse to tissue at the ablation site during the detected refractory period. (17) The system of embodiment 16, wherein the processor is configured to control the IRE pulse generator to apply the IRE pulse in response to receiving at least one of the ECG signals indicative of a sinus rhythm pulse. (18) The system of embodiment 13, comprising one or more electrodes attached to a catheter inserted into the ablation site of the patient's heart and configured to perform at least one of: (i) sensing intracardiac ECG signals at the ablation site; and (ii) applying one or more irreversible electroporation (IRE) pulses to tissue at the ablation site.

Claims

1. 1. A system for performing irreversible electroporation during cardiac refractory periods, comprising: one or more electrodes configured to sense a body surface electrocardiogram (BSECG) signal of the patient's heart; one or more electrodes configured to sense an intracardiac electrocardiogram (ICECG) signal; 1. A processor, comprising: acquiring both the BSECG signal and the ICECG signal to detect sinus rhythm; detecting the sinus rhythm based on the acquired BSECG signal, the acquired ICECG signal, or both the acquired BSECG signal and the acquired ICECG signal; Identifying a refractory period of the patient's heart during the detected sinus rhythm; and performing ablation at the ablation site during the identified refractory period; and a processor configured to:

2. 2. The system of claim 1, wherein the one or more electrodes configured to sense the ICECG signal include at least a first electrode attached to a catheter and configured to sense the ICECG signal at the ablation site, and the one or more electrodes configured to sense the BSECG signal include a second electrode coupled to a surface of the patient and configured to sense the BSECG signal of the patient's heart.

3. 10. The system of claim 1, comprising an irreversible electroporation (IRE) pulse generator configured to apply an IRE pulse to tissue at the ablation site during the identified refractory period.

4. 4. The system of claim 3, wherein the processor is configured to control the IRE pulse generator to apply the IRE pulse in response to receiving at least one of the BSECG signal and the ICECG signal indicative of the sinus rhythm.

5. 4. The system of claim 3, wherein the IRE pulse generator is configured to apply one or more bipolar IRE pulses between a pair of electrodes in contact with tissue at the ablation site and configured to sense the ICECG signal.

6. The system of claim 2 , wherein the first electrode is configured to apply one or more irreversible electroporation (IRE) pulses to tissue at the ablation site.

7. 1. A system for performing irreversible electroporation during cardiac refractory periods, comprising: an interface configured to receive body surface electrocardiogram (BSECG) and intracardiac electrocardiogram (ICECG) signals of the patient's heart; 1. A processor, comprising: acquiring both the BSECG signal and the ICECG signal to detect sinus rhythm; detecting the sinus rhythm based on the acquired BSECG signal, the acquired ICECG signal, or both the acquired BSECG signal and the acquired ICECG signal; Identifying a refractory period of the patient's heart during the detected sinus rhythm; and performing ablation at the ablation site during the identified refractory period; and a processor configured to:

8. 8. The system of claim 7, comprising an irreversible electroporation (IRE) pulse generator configured to apply an IRE pulse to tissue at the ablation site during the identified refractory period.

9. 9. The system of claim 8, wherein the processor is configured to control the IRE pulse generator to apply the IRE pulse in response to obtaining at least one of the BSECG signal and the ICECG signal indicative of the sinus rhythm from the interface.

10. 8. The system of claim 7, comprising at least a pair of electrodes mounted on a catheter configured to be inserted into the ablation site of the patient's heart and configured to: (i) sense the ICECG signal at the ablation site; and (ii) apply one or more irreversible electroporation (IRE) pulses to tissue at the ablation site.

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