Devices for delivery of electric pulses to treat various conditions

Abstract

Cell death of mammalian cells is achieved by a treatment apparatus comprising a controller, a drive circuit controlled by the controller to generate drive pulses, and at least two electrodes or electrode portions linked with the drive circuit for delivering the pulses. The apparatus may be configured for treatment of conditions such as diabetes, obesity and GI tract bleeding. The controller causes the drive circuit to provide pulses in: (a) a first group of pulses sufficient to create / open cell pores and / or disrupt cell membranes of tissue near the electrodes, (b) a second group of one or more pulses with lower voltages (e.g., electrophoretic pulses), and (c) repetition of (a) and (b) in N cycles, N having a value of 0 to 100. This may achieve cell death with lower voltages and less patient discomfort. Artificial intelligence and / or machine learning models and algorithms are described.

Description

[0001] SYSTEMS, DEVICES AND METHODS FOR DELIVERY OF ELECTRIC PULSES TO TREAT VARIOUS CONDITIONS

[0002] RELATED APPLICATIONS

[0003] The present application claims priority to European Application No. EP24212232.3 filed 11 November 2024; and is related to WIPO Publication No. WO2024 / 235826 filed May 9, 2024 and published November 21, 2024 and to WIPO Publication No. WO2024 / 047215 filed September 1, 2023 and published March 7, 2024 and to WIPO Publication No. WO2023 / 161492 filed February 27, 2023 and published August 31, 2023; the entire contents of each of which are hereby incorporated herein by reference.

[0004] FIELD

[0005] The disclosure herein is directed to the field of pulsed electric field or electric pulse treatment (e.g., reversible electroporation and / or electrophoretic pulses), including but not limited to treatment of tissue in the gastrointestinal (GI) tract, cardiac anatomy or vasculature, where the preservation of the extracellular matrix, nerve endings and vascular structures may be desired. Artificial intelligence (Al) and / or machine learning (ML) techniques and models (e.g., via supervised learning, unsupervised learning, generative artificial intelligence, etc.) are described herein to facilitate enhanced or improved analysis or interpretation of medical imaging and / or to provide treatment recommendations or predicted treatment outcomes.

[0006] Conditions to be treated and / or prevented may include but are not limited to gastrointestinal conditions (e.g., gastrointestinal cancer, Barrett’s Esophagus, colorectal polyps), heart conditions (e.g., atrial fibrillation, ventricular tachycardia), metabolic conditions (e.g., diabetes, such as Type 2 diabetes, Type 1 diabetes, hybrid or double diabetes, prediabetes, metabolic syndrome, hyperglycemia, hypertension, hypertriglyceridemia, fatty liver conditions, lipid disorders, mitochondrial disorders), obesity, ear nose and throat conditions (e.g., tonsillitis, nasal polyps, rhinitis), urological conditions (e.g., bladder cancer, cervical cancer, benign prostate hyperplasia), thyroid conditions (e.g., thyroid cancer), respiratory conditions (e.g., lung cancer, chronic bronchitis), cutaneous conditions (e.g., melanoma, non-melanoma skin cancer), pain management, renal denervation (e.g., resistant hypertension), brain conditions (e.g., glioblastoma), polycystic ovary syndrome, kidney disorders, and / or other conditions.

[0007] INTRODUCTION

[0008] Electroporation is the process of applying an electrical pulse of sufficient magnitude to a living cell to induce the creation of pores which transect the cell membrane. Electroporation has become established as a safe and effective clinical tool which in permeabilizing the cell membrane enables the rapid passive diffusion and targeted uptake of therapeutic agents.

[0009] Reversible Electroporation (RE) is electroporation which is present for a period of time before the pores on the membrane reseal and the cell recovers. Irreversible Electroporation (IRE) is electroporation in which the cell membrane is incapable of repairing after the pore formation sufficiently to perform its function of managing cell contents and consequently a process of cell death is triggered. Traditionally, Irreversible Electroporation requires the delivery of a greater amount of energy, e.g., higher voltage or a larger quantity of pulses than Reversible Electroporation.

[0010] Passage of electric current through a tissue produces Ohmic heating in accordance with Joule’s law. Ohmic heating is a function of local current density and tissue resistivity. In general, when delivering Irreversible Electroporation for the purposes of tissue ablation, generation of excess heat during ablation is undesirable as heat, although an effective tissue destroyer, tends to destroy the extra-cellular matrix that supports the cells and thus healthy tissue regeneration is prevented. Thermally induced cell death can result in damage to healthy tissue structures, impede healing and risk a perforation or fistula forming in the lumen of the gastrointestinal tract or other tissue structures.

[0011] References herein to irreversible electroporation (IRE) and reversible electroporation (RE) are used in accordance with conventional terminology in the literature to describe experimental fieldstrength thresholds observed in biological tissues.

[0012] Pulsed Field Ablation (PFA) has emerged as a promising technique for treating cardiac arrhythmias, particularly atrial fibrillation. The primary mechanism of PFA involves the application of high-voltage electrical pulses that create permanent nanopores in cell membranes, leading to cell death. These approaches are generally referred to as Irreversible Electroporation (IRE) and represent one known pulsed-field modality.

[0013] However, the rapid delivery of high-energy pulses can cause resistive (Joule) heating in the tissue. This heating is a function of the tissue’s electrical conductivity and the intensity and duration of the applied pulses. A study published in EP Europace (https: / / academic.oup.com / europace / article / 24 / 8 / 1213 / 6569081) discusses the biophysics of PFA, noting that although PFA is largely non-thermal, the energy delivered can cause a transient temperature increase in the targeted tissue.

[0014] Despite its advantages, PFA presents several challenges and potential side effects that may limit its widespread clinical adoption. These challenges and side effects may include, for example, the risk of coronary spasm, transient phrenic nerve paralysis, haemolysis, acute renal failure, and patient discomfort due to inadvertent movement during the procedure. Additionally, the loss or lack of intracardiac electrograms (iEGMs) can impede real-time monitoring.

[0015] The invention addresses these issues.

[0016] SUMMARY

[0017] We describe various methods, apparatus and devices as set out in the accompanying description and claims. For example, we describe in the following claims appended hereto:

[0018] - apparatus as set out in claim 1-55;

[0019] - uses as set out in claims 56-58;

[0020] - apparatus as set out in claims 59 and 60, which in turn refer to the Detailed Description and Summary of the specification;

[0021] - apparatus as set out in claims 61 to 75, with particular emphasis on controller / processor aspects;

[0022] - a kt as set out in claim 76;

[0023] - uses as set out in claims 77 and 78;

[0024] - a method of manufacture of an apparatus as set out in claim 79; and

[0025] - methods of treatment as set out in claims 80 to 151.

[0026] Certain implementations described herein preferably involve a combination of initial reversible (RE) electroporation followed by electrophoresis pulses for ion migration to cause cell death. The apparatus and methods may be used to treat various conditions, such as cardiac-related conditions, metabolic conditions, gastrointestinal conditions, tumors, kidney conditions, liver conditions, urology conditions, ear-nose-throat conditions, cutaneous conditions, respiratory airway conditions, and / or the like. Reversible electroporation (RE) and electrophoresis method steps combined in this manner are complementary and can be very effective for a range of treatments such as duodenal mucosal resurfacing or stopping bleeding in the gastrointestinal tract, without risk of excessive Ohmic heating as might be caused by IRE and without requiring the use of irrigation or other cooling mechanisms to reduce the Ohmic heating. In some embodiments, non-thermal electric pulse modalities described herein may be used that do not rely on pore formation or permanent membrane permeabilization to achieve tissue modification.

[0027] In accordance with several embodiments, this disclosure relates to such electric pulse modalities, in which tissue modification is effected by electric field driven processes distinct from electroporation, such as charge redistribution or electrophoretic phenomena inherent to current flow in biological tissue.

[0028] In accordance with several embodiments, the energy delivery described herein achieves tissue modulation (e.g., ablation) through electric pulse-driven charge transport or electrophoretic mechanisms, without membrane permeabilization or thermal injury. In accordance with several embodiments, the techniques described herein are directed to non-IRE electric-pulse therapy, in which tissue modification results from electric-field-driven processes with charge transport or electrophoretic effects, rather than from membrane pore formation characteristic of electroporation.

[0029] Several embodiments of the systems and methods described herein incorporate use of integrated automated or semi-automated algorithms, artificial intelligence techniques, one or more machine learning models, one or more neural networks, and / or deep learning techniques to facilitate improvements to therapy (e.g., faster therapy, more efficient therapy, therapy with improved confidence of success, personalized or patient-specific therapy, providing clinicians with therapeutic options or alternatives or treatment recommendations).

[0030] In some embodiments, the artificial intelligence and / or machine learning algorithms, models or techniques may advantageously provide enhanced medical imaging analysis or interpretation (e.g., measurements, dimensions, other quantitative or qualitative metrics, tissue type differentiation or characterization (e.g., mucosa vs. muscle or cancer tissue vs. normal healthy tissue), lumen layer differentiation (e.g., mucosal layer vs. submucosal layer)) of medical images (e.g., endoscopic images).

[0031] In more detail, several embodiments of the disclosure provide methods which comply with the following steps and apparatus with a controller and probe (e.g., catheter) with one or more electrodes for performing the steps. The steps include:

[0032] (a) a reversible electroporation group of pulses to create / open cell pores and / or disrupt cell membranes of tissue near the one or more electrodes,

[0033] (b) a secondary group of one or more electrophoretic pulses, and

[0034] (c) repetition of (a) and (b) in N cycles, N having a value of 0 to 100 (e.g., 1 to 10, 5 to 30, 10 to 40, 15 to 45, 20 to 50, 30 to 60, 40 to 70, 50 to 80, 60 to 90, 70 to 100, overlapping ranges thereof, or any value within the recited ranges).

[0035] In accordance with several embodiments, the pulse delivery described herein may be deviceagnostic and may be provided by a probe or catheter configured to operably connect to the controller (e.g., generator). In accordance with several embodiments, the result of the methods are death of targeted cells, such as cancer cells, but this is advantageously achieved without need to perform IRE and the attendant risk of excessive heating. In accordance with several embodiments, the inventors have realized counter-intuitively that cell death (ablation) can be achieved in a method that begins with application of pulses of the reversible (RE) electroporation type. This is achieved by virtue of, in each of the N cycles, then applying electrophoretic pulses to cause migration of molecules (e.g., ions) which cause cell death, instead of achieving cell death by the pores remaining open. In some embodiments, the group (b) of pulses include pulses having parameters to induce a stress on the cell membrane, enlarging the cell pores from the group (a) pulsing and thereby facilitating electrophoresis within the tissue, accelerating the loss of ions / molecules from the electroporated cells, reducing the capacity for recovery and triggering non-thermal cell death. The electrophoretic pulses may advantageously reduce inflammatory burden (e.g., for sensitive GI tissue). The RE electroporation which is applied initially is used by the subsequent electrophoresis to draw critical ions / molecules out of the cells, thereby causing cell death. The electrophoresis involves applying an electrical field to cause this migration, and it is preferably applied by a series of low voltage pulses (e.g., biphasic pulses or monophasic pulses), but it could be one continuous voltage in certain circumstances.

[0036] In accordance with several embodiments, the therapy protocol described above and elsewhere herein results in procedures that are faster, require less total energy, require lower voltage levels, and facilitate treatment of longer, circumferential lengths of tissue in a shorter amount of time than techniques involving irreversible electroporation or pulsed field ablation. The therapy protocol may advantageously result in a low cost-of-goods for the generator, may be deliverable in an outpatient setting that does not require general anesthesia, and results in primarily apoptotic cell death as opposed to tissue necrosis.

[0037] The controller may advantageously set the value of N and / or the voltage levels for the steps (a) and (b) in order to maintain a tissue temperature below 60 °C, below 50 °C or below 40 °C. This allows cell treatment without excessive heating, which is something that may occur with IRE. The value of N may be set automatically by the controller or upon input from a user.

[0038] The controller may optionally be linked with a temperature sensor for detecting or estimating temperature of tissue being treated and it automatically sets the value ofN and / or the voltage levels for the steps (a) and (b) in order to maintain a tissue temperature below 60 °C.

[0039] The controller may incorporate use of artificial intelligence and / or machine learning algorithms or techniques to set the value of N and / or the voltage levels based on trained neural networks trained on data collected from subjects over a period of time.

[0040] The treatment is in various examples sufficient to achieve in a mammal one or more results or effects selected from: ablation of tissue, such as in the heart, GI tract, or any other organ or body lumen; or haemostasis, such as in a lumen such as the GI tract or the stomach, killing the cells that are causing the bleeding; or duodenal muocosal resurfacing, such as for a metabolic condition, such as Type 2 diabetes.

[0041] In some embodiments, the treatment may result in weight loss to reduce obesity. For example, the treatment may be an effective replacement for glucagon-like peptide-1 (GLP-1) receptor agonists. In some embodiments, the electric pulse therapy described herein may be administered together with GLP-1 receptor agonists as a combined therapy.

[0042] Techniques described herein may include delivery of pulses with parameters configured to provide reversible electroporation followed by pulses with parameters configured to cause electrophoresis. In accordance with several embodiments, this combination of pulses provides targeted, quick and efficient treatment (e.g., effective ablation or cell death) without generating appreciable resistive heating. In accordance with several embodiments, the delivery of reversible electroporation pulses or electrophoretic pulses alone would not cause a desired effect but when applied sequentially in combination, they synergistically trigger a non-thermal mechanism of action that leads primarily to apoptotic cell death. This mode of cell death may be particularly advantageous for therapeutic applications in the gastrointestinal tract or other sensitive areas, as it preserves the structural integrity of the surrounding tissue. Although irreversible electroporation is one known pulsed-field mechanism for achieving non-thermal ablation (it is not heating as such which causes cell death but is rather a side effect in some cases). In accordance with several embodiments, the embodiments described herein are non-IRE and achieve comparable or superior tissue effects without relying on permanent membrane pore formation. The applied electric fields may involve electric field driven electrophoretic ion migration out of the cells, such as charge redistribution.

[0043] In accordance with several embodiments, the techniques may be used to ultimately result in pulsed field ablation or irreversible electroporation or other ablation or modulation of tissue (e.g., nervous tissue, renal tissue, airway tissue, gastrointestinal tissue, abnormal tissue (e.g., cancerous, pre- cancerous, or non-cancerous tumors or growths) in various locations (e.g., GI tract, brain, organs, vessels), polyps, hernias, ulcers, inflamed tissue, varices, tears, bleeds, and / or organs or tissue within the cardiac space or the pericardial space). The tumors or growths to be treated may be internal or external.

[0044] RE uses short, high-voltage pulses (e.g., biphasic or bipolar pulses) to create nanopores in cell membranes, allowing charged ions / molecules to flow across the membrane. The electrophoresis causes (e.g., forces) such movement of some (positive or negative) charged particles out of the cells via the pores, and indeed causes (e.g., forces) some charged particles to flow into cells, depending on the charge, in response to the electrophoretic electric field.

[0045] If an irreversible electroporation apparatus were to be used for GI tract tissue haemostasis, it may be necessary to slow down pulse delivery or to cool the area with irrigation fluids. However, these methods may add complexity and time, which may be impractical in emergency settings where swift intervention may be crucial. Additionally, the high voltages typically required for effective ablation using IRE can necessitate general anaesthesia to manage patient discomfort, a requirement that is challenging to meet in the emergency department. In accordance with several embodiments, the pulse sequencing protocol described herein does not require general anesthesia and can result in a total procedure time of less than 45 minutes, less than 40 minutes, less than 35 minutes, less than 30 minutes, less than 25 minutes, less than 20 minutes, or less than 15 minutes. The energy delivery time at each location may be less than 45 seconds, less than 30 seconds, less than 25 seconds, less than 20 seconds, less than 15 seconds, or less than 10 seconds in various implementations.

[0046] In some embodiments, reversible electroporation systems, designed primarily for transient membrane permeabilization, are not configured to produce permanent tissue modification effects in tissue such as gastrointestinal tissue (e.g., in connection with duodenal mucosal resurfacing for treatment of Type 2 diabetes, obesity or other metabolic conditions or disorders). In accordance with several embodiments, the techniques described herein importantly add the electrophoresis step to cause (e.g., force) charged particle migration across the cell membranes.

[0047] By introducing lower- voltage, electrophoretic charge transport pulses following reversible electroporation, embodiments described herein enhance ion movement across the newly formed cell pores. In accordance with several embodiments, this combined approach advantageously creates a targeted ion imbalance within the cells, amplifying the cell-killing effect without generating appreciable protein denaturing heat.

[0048] As a result, in accordance with several embodiments, the combination of reversible electroporation and electrophoresis provides a non-thermal, efficient method for cell ablation, making it highly suitable for delicate tissue in the gastrointestinal tract (e.g., duodenum, jejunum and / or ileum) or cardiac anatomy or vasculature, respiratory airways (e.g., esophagus or lungs) where thermal damage may be desired to be reduced (e.g., minimized or a net increase of less than 20 degrees Celsius, less than 18 degrees Celsius, less than 16 degrees Celsius, less than 14 degrees Celsius, less than 12 degrees Celsius, less than 10 degrees Celsius, 8 degrees Celsius, less than 6 degrees Celsius, less than 5 degrees Celsius, less than 4 degrees Celsius, less than 3 degrees Celsius, or less than 2 degrees Celsius).

[0049] In accordance with several embodiments, the systems, devices and methods (e.g., pulse parameters) described herein are used to treat cardiac conditions (e.g., cardiac arrhythmias or dysrhythmias, such as atrial fibrillation, ventricular arrhythmias) or symptoms associated with such conditions. The cardiac conditions may be associated with metabolic conditions or standalone conditions.

[0050] In accordance with several embodiments, systems, devices and methods of treating and / or reducing the symptoms associated with cardiac conditions (e.g., cardiac arrhythmias) using the systems, devices and methods described herein (e.g., the “ERASE” technology employing electrophoretic ablation pulse parameters, and / or other pulse parameters described herein) advantageously enables quick treatment that removes the thermal component (e.g., Ohmic, or resistive, heating) and reduces the likelihood of complications from treatment.

[0051] In accordance with several embodiments, the systems, devices and methods (e.g., pulse parameters) described herein may be used to treat and / or prevent metabolic conditions (e.g., Type 1 or Type 2 diabetes, gestational diabetes, hybrid or double diabetes, metabolic syndrome, obesity) or symptoms associated therewith (e.g., hypertension, obesity-related disorder, fatty liver conditions such as non-alcoholic fatty liver disease (NAFLD) or non-alcoholic steatohepatitis (NASH), fatigue, insulin resistance, blurred vision, and unexplained weight loss, hypoglycaemia, hyperglycaemia, hypercholesterolemia, pre-diabetes, impaired glucose tolerance, ketoacidosis, retinopathy, diabetic heart disease, diabetic heart failure, hypertriglyceridemia, neuropathy, and nephropathy). In accordance with several embodiments, the systems, devices and methods (e.g., pulse parameters) described herein may be used to treat conditions associated with the mucosa of the GI tract (e.g., duodenumjejunum) such as mucosal dysfunction, mucosal hyperplasia, mucosal hypoplasia, duodenal or jejunal dysfunction, diet-induced intestinal maladaptation, or combinations thereof. In accordance with several embodiments, the systems, devices and methods (e.g., pulse parameters) described herein may be used to treat and / or prevent gastrointestinal bleeding, psoriasis, polycystic ovary syndrome, coronary artery disease, stroke, heart attack, dementia or other cognitive disorder or decline, either as a standalone or secondary benefit (e.g., adjunctive therapy). The systems, devices and methods may be used within the GI tract (e.g., duodenum and or jejunum) and / or within vasculature (e.g., renal and / or hepatic vasculature). In accordance with several embodiments, the systems, devices and methods (e.g., pulse parameters) described herein may be used to promote or cause weight loss (e.g., as a substitute or replacement for GLP-1 agonists). The procedure may be performed as a one-and-done procedure or multiple times over a period of weeks, months, or years.

[0052] Recently, duodenal resurfacing has been proposed as a potential treatment for chronic diseases like obesity and diabetes. This approach involves removing the majority of mucosal cells from the section of the intestine nearest the stomach, allowing a rejuvenated mucosal layer to regenerate and potentially restore healthy, non-diabetic signaling. However, conventional treatments using thermal energy on the duodenum risk overheating, which can damage deeper layers of tissue (such as the muscularis), requiring additional measures to control excessive heating. Moreover, conventional methods often produce incomplete or uneven treatment or result in a durable or permanent reduction or damage, thereby prohibiting complete regrowth. Therefore, there is a need for advanced systems, devices, and methods to more effectively treat duodenal tissue in diabetes and obesity management, such as the systems, devices and methods described herein including combined reversible electroporation and electrophoretic pulse delivery. The systems, devices and methods described herein may be performed without need for cooling and without damaging adjacent tissue. The systems, devices and methods described herein may facilitate regeneration of cells lining a duodenum or intestine without causing thermal damage or injury (e.g., thermal ablation or tissue necrosis). The regeneration of new cells may advantageously facilitate increased nutrient absorption in the duodenum or intestine, which may decrease symptoms associated with diabetes, such as insulin resistance and blood glucose levels or high blood pressure.

[0053] In accordance with several embodiments, the systems, devices and methods (e.g., pulse parameters) described herein may be used to treat and / or prevent bleeding (e.g., gastrointestinal (GI) bleeding, brain bleeds, or other internal or external bleeding). For example, GI bleeding, a potentially life-threatening condition, can affect both upper and lower sections of the GI tract and often requires immediate intervention to stabilize the patient. Upper GI bleeding (UGIB) frequently arises from conditions such as peptic ulcers, esophageal tears and esophageal varices, esophagitis, abnormal blood vessels, hiatal hernias, and abnormal growths of cancerous, pre- cancerous, or non-cancerous tissue, while lower GI bleeding (LGIB) may result from diverticular disease, inflammatory bowel disease, ulcerative colitis, proctitis, anal fissures, tumors, haemorrhoids, and / or colonic polyps. In both cases, traditional treatments often include endoscopic procedures, pharmacological interventions, or in severe cases, surgery. However, these approaches can be time-intensive, technically demanding, and may not be feasible in emergency settings where rapid control of bleeding is critical. The bleeding may include overt bleeding or occult bleeding.

[0054] The GI tract comprises delicate tissues, which can be especially vulnerable to thermal damage and complications during procedures for managing acute bleeding. Traditional methods using thermal energy to achieve coagulation often risk collateral damage, especially in the thin-walled and highly vascularized areas of the GI tract. Systems, devices and methods described herein may advantageously provide treatment without risking collateral damage or complications (e.g., pancreatis due to blockage of the ampulla of Vater or other duct, reservoir, or passage). The systems, devices and methods (e.g., pulse parameters or protocols or schemes) described herein may advantageously treat and or reduce the causes of external or internal bleeding (e.g., gastrointestinal bleeding), which causes may include, for example, tumors, polyps, hernias, varices, tears, abnormal tissue growth, inflammation). The systems, devices and methods (e.g., pulse parameters, protocols, or schemes) described herein may advantageously facilitate coagulation or occlusion (e.g., via increased uptake or delivery of coagulative or occlusive agents or materials).

[0055] In the following description, the term V / cm means an applied voltage per centimeter spacing between the electrodes or positive and negative terminals (e.g., poles). Thus, a parameter of 100 V / cm would apply to a pair of electrodes 1 cm apart and which have an applied potential of 100 V across the electrodes, or to a pair of electrodes 2 cm apart if the applied potential is 200 V across the electrodes, multiple electrodes may mean electrode portions of a single member, such as an electrode basket separated by spacers to form a bipolar electrode structure.

[0056] In certain embodiments, the described technology incorporates a secondary follow-on electrophoretic pulse sequence delivery that is delivered after a reversible electroporation type pulse sequence, the dual-phase combination being configured to influence cellular and membrane responses to the applied electric field without inducing permanent membrane pore formation or thermal damage or injury (e.g., tissue necrosis).

[0057] In several embodiments, an electroporation or electric pulse apparatus or generator (e.g., configured for treatment of cardiac conditions, bleeding (e.g., gastrointestinal bleeding, bleeding in the brain, or other internal bleeding), gastrointestinal tumors, vascular tumors, metabolic conditions (e.g., Type 2 diabetes, obesity), other conditions) or symptoms associated therewith includes a controller, a drive circuit controlled by the controller to generate drive pulses, and one or more electrodes or electrode terminals (e.g., only two electrodes, more than two electrodes) linked with the drive circuit for delivering the pulses. The controller is configured to cause the drive circuit to provide pulses in:

[0058] (a) an electroporation-type group of pulses (e.g., reversible electroporation) sufficient to create / open cell pores and / or deliver a high-field stimulus to tissue near the one or more electrodes or electrode terminals,

[0059] (b) a secondary group of one or more electrophoretic pulses, at least some of which (e.g., all of which) have lower voltages than pulses of the group (a), and

[0060] (c) repetition of (a) and (b) in N cycles, N having a value of 0 to 100 (e.g., 1 to 50, 1 to 30, 10 to 40, 20 to 50, 30 to 60, 40 to 80, 50 to 100, overlapping ranges thereof, or any value within the recited ranges).

[0061] In some respects, we describe a method of treatment of tissue of a mammal, the treatment being carried out with use of a probe having at least two electrodes or electrode terminals or poles (e.g., positive and negative) and a drive circuit controlled by a controller to generate drive pulses, wherein the controller causes the drive circuit to provide pulses in:

[0062] (a) an electroporation-type group of pulses sufficient to create / open cell pores and / or disrupt cell membranes to tissue near the electrodes,

[0063] (b) a secondary group of one or more electrophoretic pulses, and (c) repetition of (a) and (b) in N cycles, N having a value of 0 to 100, wherein the treatment is sufficient to achieve in a mammal one or more selected from: ablation of tissue, such as in the heart or any other organ; or haemostasis, such as in a lumen such as the GI tract or the stomach; or duodenal muocosal resurfacing, such as for a metabolic condition.

[0064] We also describe apparatus comprising a probe (e.g., catheter) having at least two electrodes (e.g., a single electrode basket with two electrode terminals) and a drive circuit controlled by a controller to generate drive pulses, wherein the controller causes the drive circuit to provide pulses for performance of any of the methods described herein.

[0065] In some aspects, we describe a system (e.g., a dual-phase electric pulse system) for use in the treatment of the duodenum and / or other portion of the GI tract (e.g., stomach, jejunum) to treat metabolic conditions such as Type 2 diabetes or obesity, the system comprising: a controller, a drive circuit controlled by the controller to generate electric pulses, and a probe comprising one or more (e.g., at least two) electrodes electrically coupled to the drive circuit for delivering the pulses, wherein the controller is configured to cause the drive circuit to provide pulses in:

[0066] (a) a reversible electroporation group of pulses sufficient to open cell pores and / or disrupt cell membranes of tissue near the one or more electrodes, wherein at least some of the reversible electroporation group of pulses provide a field strength in the range of 100 V / cm to 2500 V / cm (e.g., 100 V / cm to 1500 V / cm, 500 V / cm to 1500 V / cm, 800 V / cm to 1200 V / cm, overlapping ranges thereof, or any value within the recited ranges);

[0067] (b) a secondary group of one or more electrophoretic pulses, at least some of which have lower voltages than pulses of the reversible electroporation group of pulses, wherein the secondary group of pulses includes pulses having a field strength in the range of 1 V / cm to 100 V / cm (e.g., 10 V / cm to 40 V / cm, 35 V / cm to 50 V / cm, 20 V / cm to 60 V / cm, 15 V / cm to 80 V / cm, 40 V / cm to 50 V / cm, 50 V / cm to 100 V / cm, overlapping ranges thereof, or any value within the recited ranges); and

[0068] (c) repetition of the reversible electroporation group of pulses and the secondary group of one or more electrophoretic pulses in N cycles, N having a value of 0 to 100 (e.g., 2 to 20, 5 to 30, 10 to 40, 20 to 60, 40 to 80, 80 to 100, overlapping ranges thereof, or any value within the recited ranges). In some embodiments, the duodenum surface is reset at the treatment site as a result. In some embodiments, the metabolic signaling pathway is reprogrammed and the surface is not reset.

[0069] In other aspects, we describe a system for use in the treatment of a tract or body lumen or passage in a mammal, the system comprising: a controller, a drive circuit controlled by the controller to generate electric pulses, and a probe comprising at least two electrodes electrically coupled to the drive circuit for delivering the pulses, wherein the controller is configured to cause the drive circuit to provide pulses in:

[0070] (a) a reversible electroporation group of pulses sufficient to open cell pores and / or disrupt cell membranes of tissue near the electrodes, wherein at least some of the reversible electroporation group of pulses provide a field strength in the range of 100 V / cm to 2500 V / cm;

[0071] (b) a secondary group of one or more electrophoretic pulses, at least some of which have lower voltages than pulses of the reversible electroporation group of pulses, wherein the secondary group of pulses includes pulses having a field strength in the range of 1 V / cm to 100 V / cm; and

[0072] (c) repetition of the reversible electroporation group of pulses and the secondary group of one or more electrophoretic pulses in N cycles, N having a value of 0 to 100 (e.g., 2 to 20, 5 to 30, 10 to 40, 20 to 60, 30 to 80, 40 to 90, 50 to 100, overlapping ranges thereof, or any value within the recited ranges) so that there is sufficient ablation to improve a condition such as benign prostrate hyperplasia (BPH), bladder cancer, urologic ablation in oncology.

[0073] In some examples, the group (b) of pulses include pulses having parameters to induce a stress on the cell membrane, enlarging the cell pores from the group (a) pulses and to facilitate electrophoresis within the tissue, accelerating the loss of ions from the electroporated cells, thereby reducing the capacity for recovery and triggering non-thermal cell death, without relying on or introducing IRE or permanent membrane pore formation.

[0074] In some examples, at least some of said (b) group of pulses have parameters to trigger cell death without destruction of an extracellular matrix. In some examples, the (a) group comprises a series of M bursts of pulses, each burst having a plurality of pulses. In some examples, at least some of the (a) group comprises bipolar / biphasic pulses. In some examples, at least some of the (a) group of pulses have a field strength in the range of 100 V / cm to 2500 V / cm.

[0075] In some examples, at least some of the (a) group of pulses have a field strength in the range of 350 V / cm to 1500 V / cm (e.g., 400 V / cm to 1300 V / cm or 400 V / cm to 1100 V / cm, overlapping ranges thereof, or any value within the recited ranges).

[0076] In some examples, at least some of the (a) group of pulses each have a pulse length in the range of 0.1 ps to 10 ms (e.g., in the range 0.1 ps to 1 ms, in the range of 1 ps to 5 ps, in the range of 5 ps to 10 ms, overlapping ranges thereof, or any value within the recited ranges).

[0077] In some examples, at least some of the (a) group of pulses are provided in bursts of pulses separated by time delays which are greater than time delays between individual pulses, and at least some bursts each have a duration in the range of 0.1 ms to 1000 ms (e.g., in the range of 0.1 ms to 5 ms, in the range of 5 ms to 100 ms, in the range of 50 ms to 500 ms, in the range of 500 ms to 1000 ms, overlapping ranges thereof, or any value within the recited ranges).

[0078] In some examples, at least some of the (a) group of pulses are provided in bursts of pulses separated by time delays which are greater than time delays between individual pulses, and the number of bursts in each cycle is in the range of 1 to 1000 (e.g., in the range of 5 to 50, in the range of 50 to 250, in the range of 200 to 500, in the range of 5 to 30, in the range of 20 to 50, in the range of 500 to 1000, overlapping ranges thereof, or any value within the recited ranges).

[0079] In some examples, the group (b) of pulses includes pulses having a field strength in the range of 1 V / cm to 100 V / cm (e.g., in the range of 5 V / cm to 75 V / cm, in the range of 10 V / cm to 50 V / cm, in the range of 10 V / cm to 30 V / cm, in the range of 20 V / cm to 40 V / cm, in the range of 40 V / cm to 80 V / cm, overlapping ranges thereof, or any value within the recited ranges).

[0080] In some examples, at least some of the group (b) of pulses include pulses which are square wave monophasic pulses of positive or negative polarity.

[0081] In some examples, at least some of the group (b) of pulses include at least one pulse having a length in the range of 10 ms to 1000 ms (e.g., in the range of 100 ms to 1000 ms, in the range of 250 ms to 750 ms, in the range of 250 ms to 500 ms, in the range of 400 ms to 800 ms, in the range of 300 ms to 600 ms, overlapping ranges thereof, or any value within the recited ranges).

[0082] In some examples, the total time for the treatment is less than one minute (e.g., in the range of 6 ms to 20 seconds, in the range of 1 second to 10 seconds, in the range of 5 seconds to 20 seconds, in the range of 10 seconds to 30 seconds in the range of 20 seconds to 40 seconds in the range of 30 seconds to 60 seconds, in the range of 10 seconds to 60 seconds, overlapping ranges thereof, or any value within the recited ranges).

[0083] In some examples, the controller is configured to choose the value of N according to a volume of tissue to be treated and / or a type of tissue to be treated or condition to be treated (e.g., automated real-time selection based on trained machine learning techniques or algorithms or based on data stored in memory).

[0084] In some examples, the value of N is in the range of 1 to 100 (e.g., 2 to 10, 2 to 6, 2 to 8, 4 to 10, 5 to 9, 6 to 10, 3 to 5, 4 to 6, 10 to 50, 20 to 60, 30 to 70, 40 to 80, 50 to 100, overlapping ranges thereof, or any value within the recited ranges). In some examples, the (a) group has a total energized time in the range of 5 ms to 20 ms for each cycle.

[0085] In accordance with several embodiments, a method of treatment of tissue in a mammal is described, the treatment being carried out with use of a probe having at least two electrodes (e.g., only two electrodes, three electrodes, four electrodes, six electrodes, eight electrodes or more than eight electrodes) and a drive circuit controlled by a controller to generate drive pulses, wherein the controller causes the drive circuit to provide pulses in:

[0086] (a) an electroporation-type group of pulses (e.g., akin to those for reversible electroporation) sufficient to create / open cell pores and / or disrupt cell membranes of tissue near the electrodes,

[0087] (b) a secondary group of one or more pulses, and

[0088] (c) repetition of (a) and (b) in N cycles, N having a value of 0 to 100.

[0089] In accordance with several embodiments, an apparatus and method for treatment of tissue in the GI tract, cardiac anatomy, or vascular tissue, with reduced heating of local tissue at the treatment site, is disclosed.

[0090] In some aspects, the controller is configured to choose or select the extent of repetition (value of N) subject to avoid or prevent the tissue from heating to a desired maximum level, such as 80 °C, 70 °C, 60 °C, or 50 °C, or other values between 50 °C and 80 °C.

[0091] In one aspect, the system includes a temperature sensor arranged to detect temperature of the tissue and the repetition value according to real time temperature feedback (e.g., closed-loop temperature-controlled feedback).

[0092] In some configurations, the controller is configured to set the value of N and / or the voltage levels for the steps (a) and (b) in order to maintain a tissue temperature below 80 °C, below 70 °C, below 60 °C, below 50 °C, or any value within the range of 50 °C to 80 °C.

[0093] The systems or apparatus described herein may further include a temperature sensor for detecting or estimating / measuring temperature of tissue being treated and the controller may be configured to automatically set the value of N and / or the voltage levels for the steps (a) and (b) in order to maintain a tissue temperature below 80 °C, below 70 °C, below 60 °C, below 50 °C, or any value within the range of 50 °C to 80 °C.

[0094] In some configurations, the controller is configured to cause the primary group of pulses to comprise a series of pulses with a field strength in the range of 100 V / cm to 2500 V / cm, tailored to achieve reversible electroporation and minimize collateral tissue damage at a target treatment site (e.g., in the GI tract, in a cardiac or pericardial space, or in a vessel).

[0095] In some configurations, the controller is configured to cause the secondary group of pulses to include parameters that induce stress on the cell membrane, enlarging the pores created by the primary group and promoting (e.g., causing) electrophoresis within the tissue, thereby facilitating irreversible cell death without the destruction of the extracellular matrix.

[0096] In some configurations, the controller is configured to cause at least some pulses in the primary group to be biphasic pulses to further reduce heating during treatment.

[0097] In some configurations, the controller is configured to cause the at least some pulses in the secondary group to be biphasic pulses to further reduce heating during treatment.

[0098] In some configurations, the system or electroporation apparatus comprises a handheld housing and an electrode assembly configured for endoscopic or laparoscopic insertion. In some configurations, the system or apparatus further includes a user interface (e.g., graphical user interface with a touch screen) connected to the controller. The user interface may be configured to display information and to allow an operator to adjust the values of N and pulse parameters according to the volume and characteristics of target tissue (e.g., GI tissue). Adjusting the values of N may advantageously facilitate software- or algorithm-controlled depth control of the tissue modulation (e.g., ablation, apoptotic death, or other modification). For example, the pulsing algorithm or protocol may be software-configurable, allowing precise modulation of energy delivery to suit different tissue depths and types.

[0099] In some configurations, the system comprises a pulse modulation system configured to adjust the amplitude, duration, and polarity of each pulse in real time according to feedback of tissue impedance, allowing for adaptive control to prevent overheating. In some embodiments, the feedback utilizes artificial and / or machine learning algorithms based on trained neural networks that are trained on data collected from multiple subjects over time.

[0100] In some configurations, the electrodes are arranged on one or more expandable probe structures of one or more probes, thereby enabling precise positioning within the patient (e.g., within the GI tract) and ensuring uniform pulse distribution across a target treatment area or site.

[0101] In some configurations, the drive circuit includes an opto-isolated pulse control unit to prevent unintended voltage transfer to low-voltage control electronic circuits, enhancing operational safety.

[0102] In some configurations, the system is configured to perform the entire procedure with pulse sequences totaling at least 20 seconds for treatment of patients with acute GI bleeding or cardiac arrythmias.

[0103] In accordance with several embodiments, an apparatus of the invention induces non-thermal tissue modification in GI tissues includes a handheld housing, a drive circuit to generate customizable pulse sequences, and an electrode assembly configured for endoscopic or laparoscopic insertion. In another aspect, a method of operation of a system of any embodiment is for inducing cell ablation in gastrointestinal (GI) tissue or in cardiac anatomy or in vascular tissue or other body lumens. Electrophoresis can enhance the flow of ions or molecules through cellular membranes. After electroporation-type pulses creates pores in cell membranes, electrophoretic pulses can help move ions through these pores, creating a controlled ionic imbalance within cells. This combination aids in effective, targeted cell ablation to achieve haemostasis while reducing (e.g., minimizing) thermal damage, which is especially valuable in treatments involving sensitive tissues, such as in the gastrointestinal tract, in cardiac anatomy and / or in vasculature or other body lumens.

[0104] Several embodiments disclosed herein thereby allow rapid and effective treatment of GI bleeding, a potentially life-threatening condition, affecting upper and / or lower sections of the GI tract and which often requires immediate intervention to stabilize the patient, or other types of internal bleeding.

[0105] In accordance with several embodiments, the systems, device and methods disclosed herein are advantageous because they involve keeping the applied tissue heating to at or below a maximum level, such as 80 °C, 70 °C, 60 °C, or 50 °C (or other value between 50 °C and 80 °C).

[0106] In accordance with several implementations, a method of treatment of tissue in a GI tract of a mammal (e.g., treatment of GI bleeding) is performed with use of a probe or other device having at least two electrodes (e.g., only two electrodes or more than two electrodes) and a drive circuit controlled by a controller (e.g., generator) to generate drive pulses. The controller may cause, upon receipt of instructions stored in memory on the generator or upon receipt of parameters provided to the generator by the probe or other device, the drive circuit to provide pulses in (a) a primary group of one or more pulses sufficient to create / open cell pores and / or disrupt cell membranes of tissue near the electrodes (e.g., an electroporation-type group of pulses) and (b) a secondary group of one or more electrophoretic pulses. The two groups of pulses may be repeated in one or more cycles (e.g., 1 to 100 cycles, 2 to 10 cycles, 5 to 20 cycles, 10 to 40 cycles, 20 to 60 cycles, 40 to 100 cycles, overlapping ranges thereof, or any value within the recited ranges).

[0107] It will be appreciated that the various embodiments of the disclosure achieve cell death by way of the second step, namely electrophoresis to cause / force ion migration, without having IRE-type electroporation. The reversible electroporation may “prime” the target cells for the subsequent electrophoretic pulses to take effect. In some embodiments, the therapeutic mechanism is electrophoretic modulation of epithelial signaling or reprogramming of metabolic signaling pathways. All of the pulse parameters are selected (e.g., optimized) to reduce (e.g., minimize) tissue heating, thereby allowing effective bleeding control in a GI tract without the need for additional cooling methods and without causing collateral tissue damage. The pulse parameters or protocols may be predetermined or adjusted in real-time based on feedback, sensed data, target treatment site, patient parameters, type of tissue, condition to be treated, etc.

[0108] In accordance with several embodiments, a method for treating gastrointestinal (GI) bleeding in a patient includes positioning at least two electrodes (e.g., only two electrodes or more than two electrodes) at a bleeding site within a GI tract of the patient, delivering a primary group of electroporation pulses to induce cell membrane permeabilization near the electrodes, subsequently delivering a secondary group of lower- voltage pulses to induce electrophoresis in the target tissue, and repeating the delivery of the primary and secondary pulse groups in a controlled sequence to achieve haemostasis, whereby the method sufficiently reduces (e.g., minimizes) joule heating or resistive heating, thereby reducing or removing a need for external cooling.

[0109] The number of cycles and / or the voltage levels of the pulses and other pulse parameters may be controlled or selected by the controller in order to maintain a tissue temperature below a threshold temperature (e.g., below 60 °C, below 50 °C, below 70 °C, below 80°C).

[0110] In some configurations, the controller is linked with a temperature sensor for detecting or estimating temperature of tissue being treated. The number of cycles and the pulse parameters (e.g., voltage levels) may be adjusted in real time based on temperature measurements from the temperature sensor. The treatment may be designed to achieve haemostasis in the tissue (e.g., GI tissue).

[0111] In some configurations, the secondary group of pulses includes one or more square-wave monophasic and / or biphasic pulses with a pulse length in the range of 10 ms to 1000 ms (e.g., 10 ms to 200 ms, 50 ms to 100 ms, 40 ms to 400 ms, 100 ms to 500 ms, 200 ms to 800 ms, 400 ms to 1000 ms, 10 ms to 50 ms, overlapping ranges thereof, or any value within the recited ranges).

[0112] In various implementations, the total treatment time may be less than one minute, thereby facilitating rapid intervention in emergency care settings.

[0113] In some configurations, the primary group of pulses includes pulses with pulse lengths ranging from 0.1 ps to 10 ms (e.g., 1 ps to 5 ps, 0.1 ps to 10 ps, 5 ps to 100 ps, 100 ps to 500 ps, 500 ps to 1 ms, 1 ms to 10 ms, overlapping ranges thereof, or any value within the recited ranges), so as to improve (e.g., optimize) the balance between energy delivery and reduce (e.g., minimize) thermal effects on GI tissue or other tissue.

[0114] In some configurations, the secondary group of pulses is in the range of 1 V / cm to 100 V / cm (e.g., 1 V / cm to 50 V / cm, 1 V / cm to 20 V / cm, 5 V / cm to 50 V / cm, 20 V / cm to 80 V / cm, 40 V / cm to 100 V / cm, overlapping ranges thereof, or any value within the recited ranges), ensuring controlled electrophoretic effects while reducing / avoiding the need for fluid cooling.

[0115] In some configurations, the primary and the secondary pulses are delivered as a sequence of bursts separated by time delays, such that each burst has a duration in the range of 0.1 ms to 1000 ms, to provide sufficient recovery time for the tissue and minimize cumulative heating.

[0116] In some configurations, the pulse parameters are selected based on a specific anatomical location within the GI tract, such as esophageal, gastric, duodenal or colonic regions, to tailor treatment efficacy and safety.

[0117] In some configurations, the drive circuit includes an opto-isolated pulse control unit which is operated to prevent unintended voltage transfer to low-voltage control electronic circuits, thereby enhancing operational safety.

[0118] In some configurations, the procedure comprises pulse sequences totaling no more than 20 seconds, thereby enabling faster treatment for patients with acute GI bleeding.

[0119] In some configurations, the pulse configuration or scheme includes monopolar or bipolar modes that are adjusted depending on the tissue impedance and specific GI tract requirements, thereby enabling versatile treatment across different GI bleeding sources. The tissue impedance may be monitored via the electrodes.

[0120] In some configurations, the primary group of pulses is delivered at a field strength in the range of 100 V / cm to 1500 V / cm to create temporary cell pores without causing significant thermal damage to adjacent tissue.

[0121] The method may include adjusting the pulse parameters (including but not limited to amplitude, frequency, and pulse duration) based on tissue impedance measurements obtained during the procedure, to ensure effective bleeding control while minimizing collateral tissue impact.

[0122] In accordance with several embodiments, a method for controlling bleeding in the gastrointestinal tract includes administering a series of high-frequency, short-duration reversible electroporation pulses to the bleeding site to open cell membranes, applying a sequence of lower-voltage, prolonged pulses following the high-frequency pulses to induce non-thermal cell death, and repeating the pulse sequence for a predetermined number of cycles, wherein the bleeding is controlled rapidly (e.g., allowing for completion of the procedure in less than 1 minute).

[0123] In some configurations, the frequency and the duration of the high-frequency pulses is in the range of 100 kHz to 600 kHz (e.g., 100 kHz to 450 kHz, 250 kHz to 500 kHz, 300 kHz to 400 kHz, 400 kHz to 600 kHz, overlapping ranges thereof, or any value within the recited ranges).

[0124] In some implementations, the treatment electrodes are inserted endoscopically to the GI tract. The procedure may be performed without general anesthesia, enabling treatment in an emergency department or outpatient setting.

[0125] In accordance with several embodiments, a method of achieving haemostasis in GI or other tissues includes delivering a reversible electroporation pulse group to initiate pore formation in target cells at a bleeding site, delivering an electrophoretic pulse group of lower voltage to promote ion loss and cell destabilization, and cycling the reversible electroporation and electrophoretic pulse groups to create a cumulative non-thermal cell death effect without relying on permanent membrane pore formation (e.g., irreversible electroporation), thereby achieving rapid hemostasis while preserving surrounding tissue integrity.

[0126] In some configurations, selecting pulse parameters is based on the location of the bleeding site, where field strength, pulse duration, and pulse intervals are optimized for tissue thickness and vascularity in specific regions, such as the esophagus, stomach, or colon.

[0127] In accordance with several embodiments, a method for treating acute bleeding (e.g., GI bleeding) includes inserting a treatment probe with at least two electrodes into a body lumen, cavity or other location (e.g., GI tract) near a bleeding source, delivering a sequence of alternating high and low voltage pulses, with the high voltage pulses inducing reversible electroporation and the low voltage pulses inducing electrophoretic ablation. The method may also include modulating the pulse frequency and amplitude to minimize patient discomfort. The method may advantageously provide effective, minimally invasive hemostasis suitable for emergency intervention.

[0128] In some aspects, the pulses are delivered in a manner that achieves tissue ablation at reduced voltage levels compared to traditional methods, thereby reducing the risk of thermal damage in tissue (e.g., GI tissue).

[0129] In accordance with several embodiments, a method for managing bleeding (e.g., GI bleeding, bleeding in the brain) with an electrophoretic ablation device includes configuring the electrophoretic ablation device to deliver a first set of pulses to create reversible electroporation pores in the cells at a bleeding site within a patient (e.g., within a GI tract or brain), delivering a secondary set of pulses at a lower energy level to induce non-thermal, non-electroporative tissue sealing and hemostasis without damaging the extracellular matrix. The total treatment (which may involve multiple locations) can be completed in less than five minutes, enabling use by nonspecialist personnel in emergency or outpatient settings.

[0130] Any of the methods described herein may be performed in conjunction with an endoscope to facilitate diagnosis and / or visualization in addition to treatment. In some embodiments, the probes described herein may be coupled to an endoscope to facilitate visualization during a diagnostic and / or therapeutic procedure.

[0131] In some aspects we describe a method of treatment of bleeding (such as in the GI tract) in a mammal using any apparatus described herein, with the controller implementing the steps (a), (b), and (c) as described.

[0132] In some implementations, the group (b) of pulses include pulses having parameters to induce a stress on the cell membrane, enlarging the cell pores from the group (a) and to facilitate electrophoresis within the tissue, accelerating the loss of ions from the reversibly electroporated cells, reducing the capacity for recovery and triggering non-thermal cell death.

[0133] In some implementations, said (b) group of pulses have parameters to trigger cell death without destruction of an extracellular matrix.

[0134] In some implementations, the electrode(s) incorporate a mean of stabilizing or fixing the tissue during delivery of the pulses, e.g. utilizing vacuum or mechanical fixation. In some implementations, the treatment is to achieve haemostasis in said tissue.

[0135] We also describe the use of any of the apparatus, systems, or devices of any of the claims or summary statements for the treatment of cardiac conditions, such as arrythmias.

[0136] We also describe the use of any of the apparatus, systems, or devices of any of the claims or summary statements for the treatment of diabetes or symptoms associated with diabetes, including prediabetes.

[0137] We also describe the use of any of the apparatus, systems, or devices of any of the preceding claims for the treatment of bleeding, such as gastrointestinal bleeding.

[0138] We also describe a method of treating a bleeding condition (e.g., gastrointestinal bleeding) in a patient as described herein.

[0139] We also describe a system for treating a bleeding condition (e.g., gastrointestinal bleeding) as described herein.

[0140] We also describe a method of treating a cardiac condition (e.g., cardiac arrythmia) in a patient as described herein.

[0141] We also describe a system for treating a cardiac condition (e.g., cardiac arrythmia) as described herein.

[0142] We also describe a method for controlling bleeding in a gastrointestinal tract of a patient, the method comprising: administering a series of high-frequency, short-duration electroporation-type pulses to a bleeding site within the gastrointestinal tract to open membranes of cells at the bleeding site with a pair of electrodes of a treatment probe, wherein a frequency of the high-frequency, short-duration electroporation-type pulses is between 100 kHz and 400 kHz, a duration of each of the high-frequency, short-duration electroporation-type pulses is between 1 ps and 5 ps, and a voltage of the high-frequency, short-duration electroporation-type pulses is between 800 V / cm and 2000 V / cm; applying a sequence of lower-voltage, prolonged pulses with the pair of electrodes of the treatment probe following the administering of the series of high-frequency, short-duration electroporation-type pulses to induce non-thermal cell death of the cells with the open membranes, wherein a voltage of the lower-voltage, prolonged electrophoretic pulses is between 1 V / cm and 20 V / cm and a duration of each of the pulses is between 0.1 ms and 10 ms; and repeating the pulse sequence for a predetermined number of cycles, wherein the number of cycles is between 5 and 20 cycles, wherein a total duration of the method is less than 1 minute.

[0143] In some implementations the method further comprises endoscopically inserting the treatment probe within a patient and advancing a distal end portion of the treatment probe to the bleeding site. In some implementations the method further comprises repeating the method at multiple different locations. In some implementations the high-frequency, short-duration electroporationtype pulses comprise biphasic or bipolar pulses of alternating positive and negative polarity. In some implementations the lower- voltage, prolonged pulses comprise monopolar pulses. In some implementations each cycle has a duration of less than one minute.

[0144] In some implementations the method further comprises delivering one or more hemostatic agents to the bleeding site. In some implementations the method is performed without delivering any hemostatic agents to the bleeding site.

[0145] We also describe a system for use in the treatment of bleeding, the system comprising: a controller, a drive circuit controlled by the controller to generate electric pulses, and a probe comprising at least two electrodes electrically coupled to the drive circuit for delivering the pulses, wherein the controller is configured to cause the drive circuit to provide pulses in:

[0146] (a) a reversible electroporation group of pulses sufficient to open cell pores and / or disrupt cell membranes of tissue near the electrodes, wherein at least some of the reversible electroporation group of pulses provide a field strength in the range of 100 V / cm to 2500 V / cm;

[0147] (b) a secondary group of one or more electrophoretic pulses, at least some of which have lower voltages than pulses of the reversible electroporation group of pulses, wherein the secondary group of pulses includes pulses having a field strength in the range of 1 V / cm to 100 V / cm; and

[0148] (c) repetition of the reversible electroporation group of pulses and the secondary group of one or more electrophoretic pulses in N cycles, N having a value of 0 to 100, preferably 2 to 20.

[0149] In some implementations the reversible electroporation group of pulses comprise biphasic or bipolar pulses of alternating positive and negative polarity.

[0150] In some implementations the reversible electroporation group of pulses have a pulse width of between 1 ps and 5 ps. In some implementations the one or more pulses of the secondary group of electrophoretic pulses have a pulse width of between 0.1 ms and 10 ms. In some implementations the one or more pulses of the secondary group of electrophoretic pulses comprise monopolar pulses. In some implementations each cycle has a duration of less than one minute. In some implementations a total duration of the method is less than one minute.

[0151] In various aspects, we describe a system for treating one or more metabolic conditions of a subject, the system comprising: a controller, a drive circuit controlled by the controller to generate electric pulses, and a probe comprising at least two electrodes or electrode portions electrically coupled to the drive circuit for delivering the electric pulses, wherein the controller is configured to cause the drive circuit to provide electric pulses in:

[0152] (a) a reversible electroporation group of pulses sufficient to open cell pores, wherein at least some of the reversible electroporation group of pulses provide a field strength in the range of 100 V / cm to 1500 V / cm;

[0153] (b) a secondary group of one or more electrophoretic pulses, wherein the secondary group of one or more electrophoretic pulses have a field strength in the range of 1 V / cm to 100 V / cm; and

[0154] (c) repetition of the reversible electroporation group of pulses and the secondary group of one or more electrophoretic pulses in N cycles, N having a value of 1 to 50, so that the cells of the duodenum surface at the treatment site experience non-thermal cell death.

[0155] In some implementations, the field strength of the reversible electroporation group of pulses is 1000 V / cm or less, wherein the field strength of the secondary group of one or more electrophoretic pulses is between 20 V / cm and 70 V / cm, wherein the reversible electroporation group of pulses and the one or more electrophoretic pulses each comprise biphasic pulses, and wherein N has a value less than 20.

[0156] In some implementations, a pulse width of the reversible electroporation group of pulses is between 1 and 5 microseconds and wherein a pulse width of the one or more electrophoretic pulses is between 20 and 200 milliseconds.

[0157] In some implementations, the reversible electroporation group of pulses comprises multiple bursts of pulses prior to the secondary group of one or more electrophoretic pulses.

[0158] In some implementations, the field strength of the one or more electrophoretic pulses is lower than the field strength of the reversible electroporation group of pulses.

[0159] In some implementations, the subject has been determined to have grown tolerant to one or more GLP-1 agonists or semaglutides over a determined period of time.

[0160] In some implementations, the subject has been determined to be sufficiently responsive to one or more GLP-1 agonists or semaglutides over a determined period of time.

[0161] In some implementations, the probe comprises a single expandable electrode basket comprising spacers positioned along wires of the expandable electrode basket so as to electrically isolate a first portion and a second portion of the expandable electrode basket, with the first portion configured to act as a positive electrode terminal and the second portion configured to act as a negative electrode terminal, thereby forming a bipolar electrode.

[0162] In some implementations, the wires of the expandable electrode basket are formed of a shape memory material such that the expandable electrode basket is self-expandable and configured to conform to various dimensions along a length of the duodenum.

[0163] In some implementations, at least a portion of the expandable electrode basket is configured to circumferentially contact a luminal surface of the duodenum.

[0164] In some implementations, the spacers are configured to maintain a uniform spacing between the first portion and the second portion of the expandable electrode basket regardless of an extent of expansion of the expandable electrode basket. In some implementations, the system further comprises one or more algorithms stored in memory of the controller that are configured to alter the value of N to control a depth of a treatment zone formed by the electric pulses.

[0165] In some implementations, the one or more metabolic conditions comprise one or more of diabetes or obesity.

[0166] We also describe a method of treating one or more metabolic conditions of a subject, the method comprising:

[0167] (a) delivering a reversible electroporation group of pulses sufficient to open cell pores along a circumferential portion of a mucosal layer of a duodenum of the subject, wherein at least some of the reversible electroporation group of pulses have a voltage of 100 V to 1500 V;

[0168] (b) following delivery of the reversible electroporation group of pulses, delivering a secondary group of electrophoretic pulses to the cells along the circumferential portion of the mucosal layer of the duodenum of the subject, wherein the secondary group of electrophoretic pulses have a voltage of 1 V to 100 V; and

[0169] (c) following delivery of the secondary group of electrophoretic pulses, repeating steps (a) and (b) in a plurality of cycles, wherein after the plurality of cycles, the cells along the circumferential portion of the mucosal layer of the duodenum of the subject experience non-thermal cell death.

[0170] In some implementations, the voltage of the reversible electroporation group of pulses is 1000 V or less, wherein the voltage of the secondary group of electrophoretic pulses is between 20 V and 70 V, wherein the reversible electroporation group of pulses and the electrophoretic pulses each comprise biphasic pulses, and wherein the plurality of cycles is less than 20.

[0171] In some implementations, a pulse width of the reversible electroporation group of pulses is between 1 and 5 microseconds and wherein a pulse width of the electrophoretic pulses is between 20 and 200 milliseconds.

[0172] In some implementations, the reversible electroporation group of pulses comprises multiple bursts of pulses prior to the secondary group of electrophoretic pulses.

[0173] In some implementations, the voltage of the electrophoretic pulses is lower than the voltage of the reversible electroporation group of pulses. In some implementations, the subject has been determined to have grown tolerant to one or more GLP-1 agonists or semaglutides over a determined period of time.

[0174] In some implementations, the subject has been determined to be sufficiently responsive to one or more GLP-1 agonists or semaglutides over a determined period of time.

[0175] In some implementations, the delivery of the reversible electroporation group of pulses and the electrophoretic pulses is provided by a probe comprising a single expandable electrode basket comprising spacers positioned along wires of the expandable electrode basket so as to electrically isolate a first portion and a second portion of the expandable electrode basket, with the first portion configured to act as a positive electrode terminal and the second portion configured to act as a negative electrode terminal, thereby forming a bipolar electrode.

[0176] In some implementations, the wires of the expandable electrode basket are formed of a shape memory material such that the expandable electrode basket is self-expandable and configured to conform to various dimensions along a length of the duodenum.

[0177] In some implementations, at least a portion of the expandable electrode basket is configured to circumferentially contact a luminal surface of the duodenum.

[0178] In some implementations, the spacers are configured to maintain a uniform spacing between the first portion and the second portion of the expandable electrode basket regardless of an extent of expansion of the expandable electrode basket.

[0179] In some implementations, the method further comprises altering the number of cycles to control a depth of a treatment zone formed by the electric pulses.

[0180] In some implementations, the one or more metabolic conditions comprise Type 2 diabetes. In some implementations, the one or more metabolic conditions comprise obesity. In some implementations, the one or more metabolic conditions comprise metabolic syndrome.

[0181] In some implementations, the method further comprises repeating steps (a) to (c) of any example described herein at one or more additional locations along a length of the duodenum of the subject. In some implementations, the method further comprises repeating steps (a) to (c) of any example at one or more additional locations within a jejunum of the subject.

[0182] In some implementations, the method is performed in less than 45 seconds.

[0183] In some implementations, the method is performed in less than 30 seconds.

[0184] In some implementations, the cell death of the mucosal layer causes new cells to grow to replace the dead cells over a period of time.

[0185] We also describe use of any of the systems, apparatus, devices described herein to treat subjects determined to have grown tolerant or resistant to treatment using GLP-1 agonists or semaglutides after a period of time or from initiation of treatment.

[0186] We also describe a method of treating subjects determined to have grown tolerant or resistant to treatment using GLP-1 agonists or semaglutides after a period of time or from initiation of treatment.

[0187] We also describe a library of images collected by the systems and methods of any one of the examples described herein, wherein said library is analyzed using artificial intelligence (Al) or machine learning (ML) models to generate higher confidence levels in determining vascular morphology or diagnosis, wherein the library optionally comprises data related to one or more of a patient’s age, gender, comorbidities, diet, activity level, genetic predisposition, biomarkers, other images and scans, and other risk enhancing or risk mitigating factors.

[0188] We also describe a kit comprising one or more of the catheters, generators or controllers executing one or more artificial intelligence (Al) or machine learning models or algorithms as described herein along with instructions for use.

[0189] We also describe a use of any of the devices, systems and methods according to any one of the preceding claims, with application of artificial intelligence (Al) to determine patient eligibility or likelihood of favorable response to treatment and additionally use of the system and Al to reduce risk that the subject receives unnecessary further interventions (e.g., if determined that therapy would not be successful based on non-responsiveness of the subject to prior GLP-1 or semaglutide treatment). We also describe a method of manufacture of any of the devices and systems having one or more of the features described in the foregoing description.

[0190] In some preferred examples, the controller comprises digital data processors configured to perform at least some control steps according to trained models such as artificial intelligence Al or machine learning ML trained neural network modes, and in which the controller comprises digital data processors and memories located either locally or remotely such as in the Cloud.

[0191] In some preferred examples, the models are trained based on collection of data from subjects over a period of time, and the controller is configured to provide pulse protocols according to any one or more of data collection, data analysis, image interrogation and analysis, patient candidate selection or assessment, treatment recommendations and / or predictions.

[0192] In some preferred examples, the controller is configured to access a library of data collected from multiple patients over time.

[0193] In some preferred examples, the controller is configured to, after a treatment has been performed, capture and anonymize treatment data and upload said data to a cloud computing server or network, and said neural networks are configured to be trained and improved based on said uploaded data.

[0194] In some preferred examples, the controller is configured to execute algorithms trained according to said models to identify or segment tissue types or layers, for example to identify or determine various lumen boundaries or layers in images and to calculate diameters or other cross-sectional dimensions or treatment depths based on the lumen boundaries or layers; and preferably the controller is configured to execute said algorithms to recommend portions of length of a lumen to treat and / or the depth of tissue to treat.

[0195] In some preferred examples, the controller is configured to use said models to predict treatment outcomes that a particular therapy will be successful for a particular patient based on a variety of factors, and to provide information to a physician to aid in making a diagnosis an / or treatment decision.

[0196] In some preferred examples, the controller is configured to determine predictive outcomes based on determinations of one or more co-morbidities associated with a disease or condition such as diabetes or obesity, in which said prediction is performed according to current levels or trends in biomarkers.

[0197] In some preferred examples, the apparatus comprises a condition sensor such as a temperature sensor and the controller is configures to use feedback from said sensor or sensors to dynamically adjust pulse drive parameters according to said feedback and said neural network models.

[0198] In some preferred examples, the controller is configured to deliver diagnostic test pulses and measure impedance over time to determine a characteristic of a tissue region, and to generate an output for a physician to assist with choice of treatment parameters.

[0199] In some preferred examples, the controller is configured to deliver said test pulses in real time and make to generate an output to either aid a physician to adjust parameters in real time or to automatically adjust said parameters in real time.

[0200] BRIEF DESCRIPTION OF THE DRAWINGS

[0201] Non-limiting features of some embodiments of the inventions are set forth with particularity in the claims that follow. The following drawings are for illustrative purposes only and show nonlimiting embodiments. Features from different figures may be combined in several embodiments. It should be understood that the figures are not necessarily drawn to scale. Distances, angles, etc. are merely illustrative and do not necessarily bear an exact relationship to actual dimensions and layout of the devices illustrated.

[0202] Fig. 1(a) is a block diagram of a treatment apparatus (e.g., generator or control system), and Fig. 1(b) shows a probe (e.g., catheter) of the apparatus or system;

[0203] Fig. 1(c) shows an illustration of a distal end portion of an embodiment of a treatment probe or catheter that can be used to deliver the pulsing protocol or sequence described herein;

[0204] Fig. 2 is a diagrammatic plot illustrating the general manner in which the treatment probe electrodes are driven,

[0205] Fig. 3 is an image showing the impact of the delivered electric field pulse protocol described herein on area treated using one type of electrode in a potato model,

[0206] Fig. 4 shows the test article, dimensions of same and a bespoke parallel plate fixture used for reliable delivery of specific electric field strengths used to generate data supporting Fig. 5 and Fig. 6,

[0207] Fig. 5 is a clustered bar chart demonstrating the influence the electrophoretic ablation drive scheme has on the number of pulses required to induce non-thermal cell death in a potato model, and in which the term “ERASE” is used, as a name for an embodiment of the pulsing protocol or sequence;

[0208] Fig. 6 is a clustered bar chart demonstrating the influence the electrophoretic ablation protocol has on the electric field intensity required to induce non-thermal cell death in a potato model, and in which the term “ERASE” is used, as a name for an embodiment of the pulsing protocol or sequence;

[0209] Figs. 7 to 9 are plots showing test results obtained from in an in-vivo mouse study, in which Fig. 7 is a control set of plots, and Figs. 8 and 9 are plots illustrating the benefits of treatment according to pulse protocols described herein, and in which the term “ERASE” is used, as a name for an embodiment of the pulsing protocol or sequence;

[0210] Fig. 10 is an illustration of the impact of the electrophoretic ablation protocol on the non- thermal cell death lethal threshold which is dimensionless as the non-thermal cell-death lethal threshold is different for different tissues, and

[0211] Fig. 11 is an illustration of the temperature increases seen with delivery of a group of exemplary high frequency pulses to a tissue without the use of the electrophoretic ablation protocol (dashed line) and delivery of the same degree of treatment with the electrophoretic ablation protocol (continuous line), and in which the term “ERASE” is used, as a name for an embodiment of the pulsing protocol or sequence; and

[0212] Figs. 12(a) and 12(b) illustrate how the treatment probe or catheter of Fig. 1(c) provides uniform, consistent ablation zones despite an extent of expansion of the expandable element of the probe or catheter. DETAILED DESCRIPTION

[0213] Several embodiments of the disclosure described herein provide a system, device or method for treatment of tissue in a GI tract, in cardiac anatomy, in vasculature, or in another body lumen that involves delivery of both electroporation and electrophoretic pulses to facilitate quick and efficient treatment at the desired treatment site with heating of local tissue at the treatment site to a chosen (e.g., predetermined) maximum level based on the pulse parameters (e.g., amplitude, pulse width, duration, change in type of pulse).

[0214] In accordance with several embodiments, an electrophoretic ablation apparatus for inducing cell ablation in gastrointestinal (GI) tissue or in a cardiac chamber or lumen or in a vessel includes a controller, a drive circuit controlled by the controller to generate drive pulses, and at least two electrodes (e.g., only two electrodes, or more than two electrodes) linked with the drive circuit for delivering the pulses, wherein the controller is configured to cause the drive circuit to provide pulses in: an electroporation-type group of pulses sufficient to create / open cell pores and / or disrupt cell membranes of tissue near the electrodes, a secondary, electrophoresis, group of one or more pulses at least some of which have lower voltages than pulses of the group (a), and

[0215] [repetition of the primary and secondary groups in N cycles, N having a value of 0 to 100.

[0216] The control of the repetition may be predetermined and fixed or may be adjusted in real time according to an intention or configuration to avoid or prevent the tissue from heating to a certain threshold level (such as 80 °C, 70 °C, 60 °C, or 50 °C or other value within this range).

[0217] In another aspect, we describe a method of operation of an electrophoretic ablation apparatus for inducing cell ablation in GI tissue, in a cardiac chamber or lumen, or in a vessel or other body lumen. The apparatus may include a controller, a drive circuit controlled by the controller to generate drive pulses, and at least two electrodes (e.g., only two electrodes or more than two electrodes) operatively connected to the drive circuit for delivering the pulses to the GI tissue. The controller provides: a primary group of electroporation-type pulses sufficient to create or open cell pores and / or disrupt cell membranes of tissue near the electrodes, a secondary group of one or more electrophoresis pulses, at least some of which have a lower voltage than pulses in the primary group, and repetition of the primary (reversible electroporation) and secondary (electrophoresis) groups in N cycles, where N has a value of 0 to 100, thereby achieving cell ablation in the GI tissue between and adjacent the electrodes with heating of the tissue being below a threshold temperature of 80 °C, 70 °C, 60 °C, or 50 °C (or other value within this range).

[0218] In one method of use, the cell ablation is performed to achieve hemostasis in the GI tract tissue or other target treatment tissue site adjacent to and between the electrodes.

[0219] Electroporation and electrophoresis are complementary techniques that, when combined as described herein, enable precise tissue ablation by using the properties of electric fields to disrupt cellular structures.

[0220] In accordance with several embodiments, the electroporation, higher-voltage, pulses create temporary or permanent nanopores in cell membranes, allowing ions and molecules to flow across the membrane and, in some cases, triggering cell death. The electrophoresis group, on the other hand cause movement of charged particles such as ions. By introducing lower- voltage, electrophoretic pulses following electroporation, embodiments described herein enhance ion movement across the newly formed cell pores. This combined approach creates a targeted ion imbalance within the cells, amplifying the cell-killing effect without relying on heat.

[0221] As a result, the combination of electroporation and electrophoresis provides a non-thermal, efficient method for cell ablation, making it highly suitable for delicate tissues like those in the gastrointestinal tract where thermal damage must be minimized, according to several embodiments of the disclosure.

[0222] After the reversible electroporation group creates pores in cell membranes of the treated tissue, the electrophoretic group of pulses can help move ions through these pores, creating a controlled ionic imbalance within cells. This combination aids in effective, targeted cell ablation to achieve hemostasis while reducing (e.g., minimizing) thermal damage, which can be especially valuable in treatments involving sensitive tissues, such as in the gastrointestinal tract or in cardiac anatomy or in sensitive vessels.

[0223] Referring to Figs. 1(a), 1(b) and 1(c), an electrophoretic ablation system or apparatus 1 comprises a main controller 2 linked with a user interface 3 and with a probe drive circuit 4, all mounted in a housing 9. The system or apparatus 1 may comprise an electric pulse or pulsed electric field generator. The controller 2 and the interface 3 provide the user-side functions, whereas the drive circuit 4 provides the pulses to a probe 50 (e.g., catheter) of the system or apparatus 1. In the illustrated example, the drive circuit 4 comprises: a pulse control unit 5 which is separated by opto-isolators 18 from the remainder of the drive apparatus 4, to avoid high voltages being inadvertently transferred to the low- voltage control electronics; a voltage generator 6 with a transformer, providing a voltage across capacitors; a pulse switching controller 7, for delivering pulses (e.g., high-frequency or low- frequency and high voltage or low voltage pulses) to probe electrodes 53 and 54; and a voltage set and maintain circuit 8.

[0224] The touch screen interface 3 is operably coupled to the controller 2 which manages the drive pulse control, and the voltage, pulse duration, polarity, and orientation. This level of control is achieved via the series of control circuits in the blocks 5-8. The pulse parameters may be pre-set and static or may be dynamically adjustable (automatically or manually). For example, the pulse parameters (such as the number of cycles N, duration, voltage amplitude, pulse widths, etc.) may be dynamically or algorithmically controllable to achieve a desired depth of treatment based on a type of tissue, based on individual patient parameters, based on neural networks trained on data collected from multiple patients or anatomies over time, and / or the like. For example, Al or ML techniques or algorithms may be applied to medical images of a particular treatment location to identify qualitative or quantitative metrics (e.g., dimensions, diameters, thicknesses, centerlines of vessels, lumens, layers of lumens, or tissue), to identify, distinguish or characterize tissue type (e.g., epithelial or mucosal tissue, muscle tissue, cancerous tissue, healthy tissue, tumors, growths, perforations, etc.), and / or to identify boundaries between layers of tissue (e.g., mucosal, submucosal, muscularis tissue of the duodenum or jejunum). The AI / ML models may be trained to identify anatomy that would respond well to the therapy described herein so that the therapy performed is more efficient (e.g., faster and so that portions of tissue are not treated that are not likely to provide a desired outcome upon receiving therapy).

[0225] The drive circuit may, for example, include structural or operational features or elements described in the Applicant’s published specification WO2021 / 043779, the contents of which are incorporated herein by reference. However, in several embodiments, the drive circuit is configured to provide pulses of a lower voltage level than described in the above publication, although the hardware architecture may be similar.

[0226] The treatment probe (e.g., catheter) 50 (shown in Fig. 1(b)) is for delivery of reversible electroporation and electrophoretic treatment or other electric field or pulse delivery to the gastrointestinal tract (e.g., portions or all of a length of a duodenum, pylorus, and / or jejunum, to cancerous and pre-cancerous regions of the gastrointestinal tract, or to other locations to address any condition that may benefit from non-thermal cell ablation or poration, such as locations of bleeding or likely bleeding, cardiac chambers or lumens, or other vessels or body lumens). The probe 50 comprises a sheath 52 within which there is a shaft 56 and within which there is a delivery wire 57, which may be optional and which may include more than one wire. Two electrical conducting wires (e.g., per electrode or per set of electrodes), not shown, extend within the shaft 56 for linking an electrical drive to the sets of electrodes on expanding bodies 53 and 54 separated along the longitudinal axis by an isolating spacer 55. This probe is merely one example of a probe that may be used in conjunction with the embodiments described herein. For example, the probe may alternatively be hand-held with the electrodes protruding longitudinally for contact with target tissue. The probe may not include an expanding body and may include two spaced-apart electrodes or plates. The probe may include structural and operational features or elements such as described in Applicant’s published applications WO / 2021 / 043779, WO / 2023 / 161492; WO / 2024 / 047215; US 2021 / 0128910, each of which are incorporated herein by reference)

[0227] Fig. 1(c) illustrates another embodiment of treatment probe or catheter 150. The treatment probe or catheter 150 is configured to deliver the electric pulses generated by the system or apparatus 1 of Fig. 1(a). For example, the treatment probe or catheter 150 is configured to provide reversible electroporation and electrophoretic treatment or other electric field or pulse delivery to the gastrointestinal tract (e.g., portions or all of a length of a duodenum, pylorus, and / or jejunum, to cancerous and pre-cancerous regions of the gastrointestinal tract, or to other locations to address any condition that may benefit from non-thermal cell ablation, such as locations of bleeding or likely bleeding, cardiac chambers or lumens, respiratory airways, or other vessels or body lumens). The treatment probe or catheter 150 comprises a sheath 152 within which there is a shaft 156 and within which there is one or more conductors or wires for electrically connecting to the system or apparatus 1. Treatment probe or catheter 150 comprises a single expandable electrode basket 153 formed of a plurality of wires arranged in a braided configuration. The expandable electrode basket 153 may be formed of nickel titanium alloy (e.g., Nitinol) or other shape memory material to facilitate self-expansion to conform to a diameter or other cross-sectional dimension of a body lumen (e.g., duodenum or jejunum). The expandable electrode basket 153 may be configured to provide circumferential contact around a body lumen at a particular location. The expandable electrode basket 153 may include isolating spacers (e.g., non-conductive, polymeric spacers) to electrically separate or isolate the wires of the of the expandable electrode basket 153 on opposite sides of the spacers 155, with each side forming an electrode terminal or pole. Thus, the expandable electrode basket 153 forms a bipolar electrode configuration with one side of the expandable electrode basket 153 as a positive pole and the opposite side of the expandable electrode basket 153 as a negative pole.

[0228] The probe structure may advantageously facilitate enablement of algorithmic depth control by the software and may advantageously ensure that the treatment zone (e.g., ablation zone) is consistent and known. For example, as shown in Fig. 1(c), the probe structure (e.g., catheter structure) may include an expandable and contractable element (e.g., self-expandable nitinol wire basket) having one or more spacers in between the electrodes or electrode terminals or portions or segments that maintain the same spacing regardless of the expanded diameter of the expandable probe structure (e.g., wire basket). Figs. 12(a) and 12(b) illustrate how the treatment zone (e.g., ablation zone) is consistent and uniform despite different expanded diameters. In Fig. 12(a), the expanded diameter EDI is smaller than the expanded diameter ED2. However, the depths Da and Db of the treatment zones in each of Fig. 12(a) and 12(b) are uniform and consistent.

[0229] In accordance with several embodiments, setting N to 2 (e.g., providing 2 cycles) may provide a superficial circumferential treatment to about 1 / 3 of a depth of a lumen or a layer of a lumen such as a mucosal layer of a duodenum and setting N to 4 (e.g., providing 4 cycles) may provide a circumferential treatment to about 2 / 3 of a depth of the lumen or a layer of the lumen. In accordance with several embodiments, this depth control ability can allow the expandable probe and generator (e.g., apparatus 1) to be used for multiple locations within the body even if the expandable probe structure is designed and configured to have a different diameter in the expanded state. For example, for esophageal locations the expanded diameter may be different than for duodenal locations but the depth control can be handled by the software without requiring significant further software development. As another example, a 45-second treatment cycle may be used for transmural ablation, while a 20-second cycle may be used for superficial mucosal treatment. When paired with the electrode design, this ensures consistent treatment depth regardless of the degree of expansion. Advantageously, the controller, in accordance with several embodiments, provides pulses which are lower in voltage in comparison to the voltage levels of the past for electroporation (e.g., irreversible electroporation) or thermal ablation treatment, including treatment of cancerous or pre-cancerous tissue.

[0230] As shown in Fig. 2, the drive circuit 4 is controlled by the controller to generate drive pulses for the electrodes (e.g., electrodes of Fig. 1(b) or to the electrode basket of Fig. 1(c)) in:

[0231] (a) an electroporation-type group of bursts, e.g., reversible electroporation group of bursts 60, (two bursts 60 in this illustration), each burst being of pulses 61 (biphasic in this example but could be monophasic in other examples), sufficient to create / open cell pores and / or disrupt cell membranes of tissue near the electrodes,

[0232] (b) an electrophoretic-like secondary group of one or more low voltage pulses 65 (in this case monophasic but could be biphasic in other cases), and

[0233] (c) repetition of (a) and (b) in N cycles, N having a value of 0 to 100, N being 0 meaning that there is no repetition and the stages (a) and (b) are only performed once.

[0234] In accordance with several embodiments, the reversible electroporation group of bursts 60 may have a voltage of between 800 and 1300 V / cm, 1000 V / cm, less than 1000 V / cm. The reversible electroporation group of bursts 60 may include 20 to 100 bursts (e.g., 20 to 60, 30 to 70, 40 to 60, 40 to 80, 50 to 100 bursts, overlapping ranges thereof, or any value within the recited ranges). The reversible electroporation group of burst may comprise biphasic pulses alternative between positive and negative with each positive and negative pulse portion having a pulse width of 1 - 10 microseconds (e.g., 1 - 3 microseconds, 2 - 4 microseconds, 3 - 5 microseconds, 4- 8 microseconds, 5 - 10 microseconds, overlapping ranges thereof, or any value within the recited ranges such as 1 microsecond, 2 microseconds, 3 microseconds, and so on). In accordance with several embodiments, there may be a gap between the reversible electroporation bursts and the electrophoretic group of pulses. The gap may be a matter of milliseconds or seconds (e.g., 1 - 20 seconds, 0.5 to 5 seconds, 5 to 10 seconds, 6- 8 seconds, 10 - 20 seconds, overlapping ranges thereof, or any value within the recited ranges). In accordance with several embodiments, the electrophoretic group of pulses may include a single burst of biphasic pulses (e.g., 1 biphasic pulse to 50 biphasic pulses, 5 to 20 biphasic pulses, 5 to 15 biphasic pulses, 10 to 30 biphasic pulses, 20 to 50 biphasic pulses, or more than 50 biphasic pulses).

[0235] In some aspects, we describe a method of treatment of tissue of a mammal, the treatment being carried out with use of a probe having at least two electrodes and a drive circuit controlled by a controller to generate drive pulses. The controller causes the drive circuit to provide pulses in the following manner to effect the desired treatment:

[0236] (a) an electroporation-type group of pulses sufficient to create / open cell pores and / or disrupt cell membranes of tissue near the electrodes,

[0237] (b) a secondary group of one or more electrophoretic pulses, and

[0238] (c) repetition of (a) and (b) in N cycles, N having a value of 0 to 100.

[0239] The treatment is sufficient to achieve in a mammal the desired treatment, and the following are examples: ablation of tissue, such as in the heart or any other organ; or haemostasis, such as in a lumen such as the GI tract or the stomach; or duodenal muocosal resurfacing, such as for a metabolic condition.

[0240] We also describe apparatus comprising a probe having at least two electrodes and a drive circuit controlled by a controller to generate drive pulses, wherein the controller causes the drive circuit to provide pulses for performance of any of the methods described herein.

[0241] In accordance with several embodiments, the voltage magnitude required to achieve non-thermal cell death through the combined sequence of reversible electroporation and electrophoretic pulses described herein is lower than Irreversible Electroporation and / or can be achieved with a lower number of pulses (e.g., high voltage pulses) and / or a shorter duration of time. The delivery of lower voltage magnitude pulses and / or less of these high voltage pulses results in lower joule heating of tissue and thus less need for consideration of the management of said heating. In accordance with several embodiments, the secondary group of one or more pulses of an order of magnitude lower voltage than the first group do induce Joule heating in and of themselves; however, this is comparatively insignificant and in aggregating all pulses and totaling Joule heating, the systems, devices and methods described herein are capable of inducing similar cell death in the target tissue at a lower overall energy delivery, thus potentially providing a safer treatment, and a clinical benefit for the recipient of the treatment.

[0242] In more detail, embodiments of the systems and devices described herein are configured to deliver pulses to achieve the following.

[0243] (a) Reversible electroporation, to disrupt the cell membrane and create pores:

[0244] - In mammalian tissue, a field strength of >100 V / cm and <2500 V / cm (e.g., in the range of 350-1500 V / cm, in the range of 400-1300 V / cm, in the range of 400-1100 V / cm, in the range of 100 V / cm to 1500 V / cm, in the range of 400 V / cm to 800 V / cm, in the range of 500 V / cm to 1000 V / cm, in the range of 1000 V / cm to 2500 V / cm, overlapping ranges thereof, or any value within the recited ranges).

[0245] - Individual Pulse length in the range of 0.1 psec - 10 ms (e.g., in the range 0.1 psec - 1ms, in the range of 0.1 psec -5 psec, in the range of 1 ms - 5 ms, in the range of 2 ms - 10 ms, in the range of 1 psec - 5 psec, overlapping ranges thereof, or any value within the recited ranges). - Energized time per pulse burst in the range of 0.05-1000 ms (e.g., in the range of 0.05-50 ms per pulse burst, in the range of 0.05-5 ms per pulse burst, in the range of 0.05 ms to 100 ms per pulse burst, in the range of 1 ms to 5 ms per pulse burst, in the range of 5 ms to 100 ms per pulse burst, in the range of 100 ms to 500 ms per pulse burst, in the range of 500 ms to 1000 ms per pulse burst, overlapping ranges thereof, or any value within the recited ranges). Total number of pulse bursts in each cycle in the range of 1-1000 (e.g., in the range of 5-50 bursts of monophasic, biphasic or sinusoidal waveforms, in the range of 1 - 20 bursts, in the range of 5 - 40 bursts, in the range of 10 - 50 bursts, in the range of 20 - 50 bursts, in the range of 50 - 100 bursts, in the range of 100 - 500 bursts, in the range of 500 - 1000 bursts, overlapping ranges thereof, or any value within the recited ranges). Each burst is delivery of a set number of individual biphasic pulses. For example, fifty biphasic pulses of 2 ps positive and 2 ps negative, giving 200 ps energised time per burst. If there are 60 bursts in a cycle (one N value) then there is a total energized time per cycle of 12 ms. In some embodiments, it is preferred that the (a) group has a total energised time per cycle in the range of 0.5 ms to 20 ms before the lower voltage, longer pulse length of group (b).

[0246] (b) Secondary Pulse Group: One or more pulses sufficient to induce a stress on the cell membrane, enlarging the pores from the first group (a) and facilitating electrophoresis within the tissue, accelerating the loss of ions from the electroporated cells, reducing the capacity for recovery and triggering non thermal cell death without destruction of the extracellular matrix:

[0247] - Voltage in the range of 1 - 100 V (e.g., in the range of 5-75 V, in the range of 10 - 50V, in the range of 1 - 25 V, in the range of 10 - 40 V, in the range of 25 - 50 V, in the range of 50 V - 75 V, in the range of 50 V - 100 V, overlapping ranges thereof, or any value within the recited ranges).

[0248] - Square wave monophasic pulse, positive or negative polarity into a monopolar or bipolar electrode. Positive or negative polarity in this sense denotes the direction a charged ion will move under the influence of the applied electric field in an electrode having just two poles there are thus two directions. For more complicated electrode designs having many poles which can act as anode or cathode it is possible that application of this electrophoretic pulse in multiple different directions may enhance the observed efficacy.

[0249] - Pulse length in the range of 10 - 10000 ms (e.g., in the range of 100-1000 ms, in the range of 250-750 ms, in the range of 1000 ms - 10000 ms, in the range of 300 ms - 600 ms, in the range of 500 ms - 1000 ms, overlapping ranges thereof, or any value within the recited ranges) delivered as a single pulse or multiple pulses until the total desired pulse length or duration is delivered.

[0250] (c) Combination and Sequence:

[0251] Electroporation-type pulse group followed by secondary pulse group.

[0252] (a) and (b) being performed from 1 - 100 times (e.g., 2-10 times, 2-6 times, 3 - 5 times, 4 - 6 times, 1 - 20 times, 5 - 50 times, 15 - 60 times, 20 times - 80 times, 40 times - 100 times, overlapping ranges thereof, or any value within the recited ranges).

[0253] In accordance with several embodiments, a reduction in the electric field threshold required to cause cell death is observed with this drive scheme. Tissue which has undergone reversible electroporation has higher conductivity than tissue which has not, and the degree of impedance change measured can reflect the degree of change induced in the tissue.

[0254] In accordance with various examples, there is a sequence of higher voltage pulses, of shorter duration followed by a sequence of lower voltage pulses (e.g., 5-20X lower voltage), with longer duration (from 2 microseconds per individual pulse to >100 ms) to cause irreversible electroporation and cell death. This combination sequence is referred to herein as ‘Electrophoretic Ablation’ .

[0255] The pulse sequence arises from the Applicant’s understanding that by using a high voltage pulse burst in the reversible electroporation range, followed by a low voltage pulse burst, will firstly create pores in the cell membrane before the low voltage pulse will stress the cell membrane enlarging the pores and draw ions out of the electroporated cell and / or place adequate stress on the electroporated cell membrane to impact the ability of the cell to recover. By repeating this pulse sequence, the volume of tissue irreversibly electroporated expands.

[0256] The controllers described herein (e.g., main controller 2, pulse control unit 5) may comprise one or more processors configured to execute instructions stored in memory that is coupled to the one or more processors to perform one or more processes or algorithms. The algorithms may comprise Al or ML algorithms based on trained neural networks. The neural networks may be trained based on collection of data from many subjects over a period of time. The controllers may be configured to facilitate or provide preset or variable electric pulse protocols such as described herein, to perform data collections, data analyses, image interrogation and analysis, patient candidate selection or assessment, treatment recommendations and. / or predictions, and adjustment to pulse protocols. The memory may include a library of data collected from multiple patients over time. In some embodiments, the library of data may be stored on one or more cloud computing servers or devices that can be accessed by one or more of the controllers described herein over a communications network. The Al and / or ML algorithms may be used with or without imaging.

[0257] In accordance with several embodiments, after each procedure or treatment is performed, anonymized data can be uploaded securely to a cloud computing server or network. The Al and / or ML models may be continuously trained and improved based on the new data that is collected over time across hundreds or thousands of cases. Improved Al and / or ML algorithms may then be distributed back to the generators around the world over a communications network, such as the Internet, thereby making every treatment safer and more effective over time.

[0258] The Al and / or ML algorithms may may include application of deep learning models, for example segment anything models (“SAM models”), U-net models, U-net++ models, V-net models, Trans- UNet models, Swin-UNet models, generative Al models, other convolutional neural networks, or other deep learning models with similar structures or variations thereof.

[0259] The Al and / or ML algorithms may include, for example, algorithms trained to identify or segment various tissue types or layers. In the context of the duodenum, the algorithms may be trained to identify or determine various lumen boundaries or layers (e.g., mucosal layer, submucosal layer, and muscularis layer) in images and to calculate diameters or other cross-sectional dimensions or treatment depths based on the lumen boundaries or layers. The algorithms may be trained to recommend portions of the length of the lumen (e.g., duodenum) to treat and / or the depth of tissue to treat. The algorithms may use stored data to determine whether a subject or patient is likely to respond favorably to the therapy described herein. The data may include, for example, past subject or patient history or parameters, such as past history of use of GLP-1 agonists, whether that subject responded well to administration of GLP-1 agonists, whether the patient has developed a tolerance to GLP-1 agonists after a period of time, weight, body mass index, age, ethnicity, other demographic data, family medical history, patient medical history, lifestyle choices such as consuming of alcohol or smoking, prior symptoms of diabetes or metabolic conditions, blood pressure, triglyceride levels, cholesterol or lipid levels, other metabolic biomarkers or genetic markers, average villi length, villi quantity, prior treatment history or medications, etc. The Al and / or ML algorithms may incorporate data received from one or more sensors or images to determine adjustments to one or more pulse parameters (e.g., amount of energy to be delivered, level of voltage of energy to be delivered, etc.).

[0260] The Al and / or ML models and algorithms may allow for customized treatment as opposed to a “one-size-fits-all” approach. Individual patient data combined with past treatment outcomes may be used to train predictive models. As one example in connection with duodenal mucosal resurfacing, the Al may predict that one patient will achieve a 3% drop in HbAlc based on metabolic and genomic indicators or other patient data, while another patient may only achieve a 1.5% drop. The system can then adjust the pulse parameters (e.g., to effect treatment of more of the length or deeper penetration of the gastrointestinal tract, such as the duodenum or jejunum).

[0261] In some embodiments, the Al and / or ML algorithms may be used to predict treatment outcomes or to predict likelihood that a particular therapy will be successful for a particular patient based on a variety of factors, such as those described above. In some embodiments, AI / ML models and techniques are used to aid the physician in making a diagnosis (e.g., by providing predictive outcomes or treatment recommendations using trained AI / ML models based on prior annotated images).

[0262] Al and / or ML may be used in real time for data collection, diagnostics, predictive outcomes and / or correlations. In one embodiment, Al and / or ML is used for predictive outcomes based on determinations of one or more co-morbidities associated with diabetes, obesity or symptoms associated therewith. Current levels or trends in biomarkers for example, inflammatory biomarkers, blood-based biomarkers such as triglycerides or cholesterol levels, other lipid and metabolic biomarkers, other coagulation and cardiac biomarkers, or other biomarkers can also be used as an input for the Al and / or ML algorithms. Images from modalities other than endoscopy may also be utilized or may be performed without any imaging.

[0263] In some embodiments, the electric pulse therapy described herein may not be performed on subjects that are determined not to respond well to GLP-1 agonists, semaglutides or similar medications (e.g., have grown tolerant to over a certain period of time or never responded well from the outset) such that tissue is not treated unnecessarily with low likelihood of efficacy. The determination may be based on the Al and / or ML algorithms.

[0264] In some embodiments, the electric pulse therapy described herein is performed on subjects that are determined not to respond well to GLP-1 agonists, semaglutides or similar medications (e.g., have grown tolerant to over a certain period of time (e.g., a period of months or years) or never responded well from the outset).

[0265] In accordance with several embodiments, Al and / or ML algorithms may provide smarter and / or safer treatment delivery that does not rely on human reaction time. The Al and / or ML algorithms may receive feedback from the probe or catheter (e.g., one or more electrodes or sensors) regarding various energy delivery, tissue or patient parameters (e.g., voltage, current, tissue impedance, and temperature during treatment or a procedure) either continuously or at various points of time. The Al and / or ML algorithms may be configured to instantly make adjustments to pulse parameters or pause delivery upon detection of a problem or abnormality (e.g., poor electrode contact, arcing, or excessive heat) — it instantly adjusts (increases / decreases). For example, during a procedure to stop gastrointestinal bleeding, the system can automatically prevent overheating of fragile tissue while still sealing the vessel.

[0266] In accordance with several embodiments, real-time Al and / or ML algorithms allow the system or clinician to provide or make real-time decisions with confidence and without relying on access to a remote server.

[0267] In accordance with several embodiments, the Al and / or ML algorithms select pulse parameters based on a particular location of a treatment site (e.g., duodenum, colon, heart, stomach jejunum, ileum) that is optimized for that tissue’s electrical and structural characteristics, thereby improving precision and reproducibility. For example, for duodenal mucosal resurfacing for Type 2 diabetes, the system can provide lower-energy, shorter pulses to treat the mucosa without damaging deeper muscle layers, reducing complications and recovery time.

[0268] In accordance with several embodiments, Al and / or ML algorithms can adapt pulse delivery and treatment strategy for various indications or targets using the same generator and probe or catheter instead of requiring multiple different hardware and / or software components, thereby making the platform scalable across multiple specialties using one core system.

[0269] In accordance with several embodiments, Al and / or ML algorithms facilitate avoidance of treatment of predefined tissue areas without distinguishing between healthy and diseased regions. This can reduce the likelihood of incomplete ablation of tissue or unnecessary damage to surrounding normal tissue. Before, during and / or after a treatment or procedure at a particular location, the controllers or control units may deliver diagnostic low-voltage test pulses and measure impedance of the tissue. The Al and / or ML algorithms may analyze these signals to detect abnormal electrical patterns, to detect or confirm ablation of tissue, etc. The system can then automatically adjust pulse parameters or procedural parameters (e.g., stop delivery) in real time. Thus, the system may function as a diagnostic and therapeutic platform capable of identifying and selectively treating tissue within the same session in an outpatient setting.

[0270] The Applicant completed the following testing in a potato model, using a probe as described in Applicant’s published US Patent Application No. US2021 / 0128910, “Cutis”. This probe has two parallel linear arrays of 4 needles which act as alternative anode and cathode during delivery of pulses. Rectangular needle arrays like this are considered, in the art, to act similar to parallel plate electrodes where the volume between the two arrays is subjected to an electric field strength approximate to that which is obtained from the following simple calculation:

[0271] Input Voltage (V)

[0272] E Field between Flat Plates (V / cm) = — - ; - — — — - — - ; — - — r

[0273] Distance between Flat Plate Electrodes (cm)

[0274] The potato model is commonly used for electroporation studies because the region exposed to higher electric field intensities becomes dark, over 12 to 36 hours after delivery of pulses, allowing a visual estimation of the ablation boundary without specialized equipment. In such reports, the darkened area is described as corresponding to the so-called irreversible electroporation (IRE) threshold of the potato cells. It should be understood that these terms are used here only as conventional reference points for comparing electric field exposure levels, not to imply that the mechanisms of the present disclosure depend on permanent membrane pore formation.

[0275] Potatoes exhibit lower electrical-field thresholds for regions conventionally labeled as irreversible (IRE) and reversible electroporation (RE) than human or animal tissues. An alternative method of demonstrating the Irreversible Electroporation region in potatoes involves the use of 2,3,5- triphenyltetrazolium chloride (TTC) which is reduced by the metabolic activity of living cells or tissues to form a red-colored by-product triphenylformazan. When applied to potato tissue the IRE area of the potato appears white and the area around this which remains metabolically active appears red. In addition to this, the area immediately surrounding the white area takes on an enhanced level or redness which is presumed in the art to relate to this area receiving reversible electroporation and thus having a higher uptake of the TTC in the cells resulting in a higher red intensity in this area as a greater number of TTC molecules have access to the metabolic activity within the cell. Fig 3 demonstrates three potatoes which have been sliced in half before treatment with the CUTIS device. On the left of each potato, the electrode delivered an electric field strength 750V / cm in the form of a series of eight square wave lOOps pulses of 300V amplitude delivered at a frequency of 5000Hz. On the right of each potato, the electrode delivered the same pulse as the left; however, this was followed with a secondary pulse to complete the method. This secondary pulse (electrophoresis, group (b)) was ten square wave 65,000ps (65ms) pulses of 50V amplitude delivered at a frequency of 1Hz.

[0276] Potato A was treated once with these pulses (N=l), Potato B was treated twice with these pulses (N=2), and Potato C was treated three times with these pulses (N=3). The potatoes were immediately taken and submerged face down in a 0.5% (by weight) TTC solution. The images in Fig 3 were obtained post 24 hours at which time the colour contrast is very well developed. These images were taken with the potatoes parallel to the plane of the camera and the camera at a height to reduce parallax error contribution. These images were then taken into a Computer Aided Design software package, Rhinoceros 7 SRI 5, scaled based off known dimensions, the outline of the metabolically dead region outlined and the software used to obtain area measurements for these bounded regions. These area measurements have been overlayed on the Fig. 3 and are tabulated in the following table.

[0277] Results should be viewed as demonstrative of the change between those areas treated with and without the invention as opposed to precise values as a result of the subjectivity of determining where exactly the color changes from white to red as this is a blurry border the operator is trying to identify as opposed to a clean definitive border line. Nonetheless, it can be seen that the invention method produces a large increase in area treated: A 39%; B 39% and C 18%. Potato A with use of the invention method protocol is almost equivalent in electroporated area demonstrated to that seen in Potato B Control. When considered that these areas are just a slice of a 3D volume treated it can be understood that the 3D volume will likely increase also in depth. It is logical that the protocols described herein will have varying degree of addition to this treated area as, with increase in the delivered dose of the pulse without invention method , there is potential you approach a degree of tissue electroporation where an invention method pulse will have minimal additional benefit, as the tissue in the relevant area has already successfully been electroporated - is thus higher in conductivity than the non-electroporated tissue and a preferential path for any electrical pulse introduced.

[0278] Example 2

[0279] The increase in treated area demonstrated in Example 1 corresponds with areas of tissue that are further from the electrodes, where lower field strengths were applied. These regions align with what is conventionally described in the literature as the irreversible electroporation threshold for similar test materials, and the terminology is used here solely as a comparative reference point for field strength. Testing was carried out using a flat plate test fixture wherein the field strength is one single value for a given test. The test fixturing and samples are illustrated in Fig. 4. Test samples 85 are cylinders of potato tissue of diameters ~18 mm and height 14.9 - 15.0 mm. These are placed between spring loaded electric plates 81 of the fixture 80 thus ensuring good electrical contact between the plates and the sample with the plates free to sit an angle if the sample has ends which are not parallel. Post test samples were sectioned with half placed in 0.5% (by weight) TTC solution and have left free to develop melanin darkening if cell death had taken place. A large number of tests were performed for different input voltages.

[0280] Fig. 5 illustrates the impact that addition of the secondary pulse protocol (referred to in prior studies as the invention method protocol) has on the number of pulse deliveries required before a fi eld- strength threshold corresponding to the region conventionally described as irreversible electroporation (IRE) is observed in a potato model.

[0281] Pulses delivered for this testing were high frequency biphasic 2-l-2ps pulses delivered in 30 bursts of 50 pulses per burst delivered at 10Hz. It can be observed that for a field strength of 250 V / cm cell death was induced after just 4 pulse deliveries with invention method versus the required 7 pulse deliveries without the invention method. It can also be observed that as the pulse strength was increased the invention method impact had less effect. It is important to remember that these thresholds are dependent not only on the tissue being treated but also attributes of the pulse being delivered, the pulse length, type and frequency of delivery in ways that are not yet close to being fully understood in the state of the art.

[0282] Fig. 6 illustrates the impact that addition of the invention method protocol has on the field strength required for cell death to be observed in a potato model. Pulse type was identical to that used for Fig. 5. When extrapolated to the higher voltages required in treating mammalian tissue this degree of difference in cell death threshold could be the difference between a given electrode or modality of treatment being feasible for reasons of patient tolerability or generator capability.

[0283] Preclinical testing has been carried out with an electroporation probe using a mouse tumor colorectal model. The treatment probe used was designed specifically for the study in order to allow delivery of pulses to the mouse tumors through the mouse skin and works similar in principle to the CUTIS in Example 1. The treatment probe designed has six 0.25 mm diameter sharp needles organized as two parallel linear arrays with a needle edge to edge distance of 3 mm. Needles extend 10 mm from the body of the electrode which has gripping features that allow the user to push the needles through the mouse skin atraumatically and control the depth of treatment.

[0284] In its use in this study the probe was considered to only have treated the cuboid of tissue bounded by the outer comers of the array and the needle depth. Therefore, in order to ensure coverage of the tumors, the device was replaced in the tissue a number of times until the entire tumor volume had received treatment. Depending on tumor volume and shape, this was between four and seven applications.

[0285] Mice were seeded in the flank with cancer cells. Tumor growth was monitored over a period of time with sufficient time allowed to elapse such that a majority of tumors were allowed to grow to between 0.8 to 1.2 cm3 in volume. Tumor volume was determined using the following equation:

[0286] 1

[0287] Volume = — Length X Width2)

[0288] All mice were remeasured, sorted by tumor size and broken into groups with similar mean and standard deviation for tumor size. Five groups were studied with five mice per group:

[0289] A) Control group, no treatment.

[0290] B) Electrochemotherapy (ECT)

[0291] C) invention method (combination parameters x 1).

[0292] D) invention method (combination parameters x 4), and

[0293] E) IRE. Fig. 7 demonstrates tumor growth in the days after index for A) “Control group, No treatment”. For ethical reasons, it is undesirable that tumors are allowed to exceed 1.5 cm3. As a result of the continued tumor growth due to lack of treatment, all mice had been culled for humane reasons by day 9 post index.

[0294] Fig 8 demonstrates tumor growth in the days after index for B) “Electrochemotherapy (ECT)”. Chemotherapeutic agent Bleomycin (250IU) was injected into the center of the tumor mass immediately before use of the electrode. The electrode delivered an electric field strength lOOOV / cm in the form of a series of eight square wave lOOps pulses of 300V amplitude delivered at a frequency of 5000Hz. This is significantly lower in both number of pulses (8«100) and field strength (lOOOV / cm < 1500 V / cm) than the requirement to induce cell death in any animal tissue and thus without addition of a chemotherapeutic should have negligible effect on tumor growth. Electrochemotherapy works based on the principle that reversibly electroporated cells have greatly enhanced uptake of a directly injected or intravenously administered chemotherapeutic drug. Reversible electroporation has been demonstrated to increase the uptake of Bleomycin in the cell cytosol resulting in a corresponding increase in its cytotoxicity of 300 - 5000-fold (Orlowski et al. 1988, Gehl et al. 1998, Jaroszeski et al. 2000a).

[0295] Fig 9 demonstrates tumor growth in the days after index for D) invention method Combination pulse x 4”, N=4. The electrode delivered for the group (a), reversible electroporation, an electric field strength lOOOV / cm in the form of a series of eight square wave lOOps pulses of 300V amplitude delivered at a frequency of 5000Hz. This is significantly lower in both number of pulses (8«100) and field strength (lOOOV / cm < 1500 V / cm) than the requirement to induce IRE in animal tissue. This was followed by delivering a series of (b) group electrophoresis pulses, ten square wave 50V (low voltage) pulses of 65,000ps (65ms) delivered at 1Hz. This sequence was delivered four times (N=4) at each placement of electrode. The addition of a suitably designed low-voltage follow-on pulse to a higher-voltage pulse, which in conventional electroporation studies would be capable of inducing transient membrane effects, has been found to extend the fi eld- strength threshold associated with loss of cell viability. This combination of pulses may be referred to herein as the ERASE protocol in accordance with the invention, which modifies the biological response to the applied electric field without relying on membrane pore formation or electroporation processes.

[0296] These pre-clinical results have shown a decrease in tumor diameter post-treatment for the combination parameters which are comparable to the results obtained in the group treated with el ectrochemotherapy .

[0297] Fig. 10 is an illustrated graph of the impact of the invention method protocol on the cell death threshold which is dimensionless as the cell death threshold is different for different tissues. The dashed line represents the cell death threshold without the application of an invention method protocol and this line is shifted down and to the left by the application of ERASE. Thus far our testing in a potato model with multiple different types of preceding electroporation-type pulse type, high and low frequency, support this representation of its impact. In addition, preliminary testing in a murine colorectal cancer model has shown efficacy of pulses at lower pulse amplitude than traditionally required to induce cell death.

[0298] Fig. 11 is an illustration of the temperature increases seen with delivery of a series of exemplary high frequency pulses to perfused ex-vivo liver tissue, using a parallel plate electrode with plate- to-plate distance 1cm, without the use of the invention method protocol and with the ERASE protocol. The dashed line represents the treatment without the use of invention method protocol; in this example a series of twelve lOOOV / cm High Frequency Biphasic Pulses are delivered with a seven second interval between deliveries. With each delivery of pulses the tissue temperature increases before decreasing somewhat before delivery of the next due heat dissipation to the surrounding tissues and environment. The tissue temperature peaks at approximately 60°C.

[0299] The solid line represents treatment with the use of the invention method protocol, in this example eight (N=8) cycles each of the same 1000 V / cm High Frequency Biphasic 2-l-2ps pulses, each cycle having 30 bursts of 50 pulses per burst delivered at 10Hz (Electrophoretic, group (a)) 15 followed by the secondary pulse (electrophoresis, group (b)) of ten square wave 65,000ps (65ms) pulses of 50V amplitude delivered at a frequency of 1Hz. These were delivered with a seven second interval between commencement of each invention method cycle.

[0300] The invention method protocol treatment can be seen to cause a tissue temperature increase to 55°C. This 5°C lower peak tissue temperature is sufficient to greatly decrease the degree of thermal tissue injury and its associated risks. Thermal tissue damage relates both to the temperature the tissue experiences and the length of time for which this temperature is sustained. It is considered that, in humans, tissue damage starts when the tissue temperature exceeds 43°C and each additional degree of increase halves the time that the tissue can be maintained at a given temperature before it becomes non-viable. It can be understood thus that when tissue achieves a peak temperature of 60°C this is significantly more damaging than achieving a peak temperature of 55°C. In addition, during its cooling towards ambient temperature the tissue spends time at each temperature value below the peak value with undesired thermal damage being cumulative.

[0301] Systems, Devices and Methods for Treating Bleeding

[0302] Systems, devices and methods (e.g., pulse parameters or invention method schemes or protocols) described herein may be used for controlling bleeding (e.g., GI tract, brain bleeding, or other internal bleeding). For example, the delivery or application of a primary group of pulses with certain pulse parameters (e.g., voltage amplitude, pulse length or width, duration) to open cell membranes and a secondary group of pulses with certain pulse parameters (e.g., voltage amplitude, pulse length or width, duration, phase type) to further enlarge the open cell membranes to cause non-thermal cell death may be provided. In various examples, the secondary group of pulses includes one or more square-wave monophasic pulses with a pulse length in the range of 10 ms to 1000 ms (e.g., 10 ms to 100 ms, 50 ms to 200 ms, 100 ms to 500 ms, 200 ms to 600 ms, 400 ms to 800 ms, 500 ms to 1000 ms, overlapping ranges thereof, or any value within the recited ranges). In some examples, the secondary group of pulses includes one or more square-wave biphasic pulses with a pulse length in the range of 10 ms to 1000 ms (e.g., 10 ms to 100 ms, 50 ms to 200 ms, 100 ms to 500 ms, 200 ms to 600 ms, 400 ms to 800 ms, 500 ms to 1000 ms, overlapping ranges thereof, or any value within the recited ranges).

[0303] The total treatment time may be less than one minute, less than two minutes, less than three minutes, less than four minutes, less than five minutes, or other length of time to facilitate rapid intervention in emergency care settings.

[0304] The primary group of pulses may preferably include pulses with pulse lengths ranging from 0.1 ps to 10 ms (e.g., 0.1 ps to 1 ps, 0.5 ps to 1.5 ps, 1 ps to 5 ps, 5 ps to 100 ps, 100 ps to 1 ms, 1 ms to 10 ms, overlapping ranges thereof, or any value within the recited ranges), so as to optimize the balance between energy delivery and reducing (e.g., minimizing) thermal effects on GI tissue.

[0305] The secondary group of pulses may preferably be in the range of 1 V / cm to 100 V / cm (e.g., from 1 V / cm to 10 V / cm, from 5 V / cm to 20 V / cm, from 10 V / cm to 40 V / cm, from 20 V / cm to 50 V / cm, from 40 V / cm to 80 V / cm, from 50 V / cm to 100 V / cm, overlapping ranges thereof, or any value within the recited ranges). The voltage range may be selected to ensure controlled electrophoretic effects while reducing the need for fluid cooling. In accordance with several examples, the primary and secondary pulses are preferably delivered as a sequence of bursts separated by time delays, such that each burst has a duration in the range of 0.1 ms to 1000 ms (e.g., from 0.1 ms to 100 ms, from 1 ms to 100 ms, from 100 ms to 500 ms, from 200 ms to 800 ms, from 400 ms to 1000 ms, from 500 ms to 1000 ms, overlapping ranges thereof, or any value within the recited ranges). The burst duration may be selected to be a particular duration that provides sufficient recovery time for the tissue and reduces (e.g., minimizes) cumulative heating.

[0306] In several aspects, the pulse delivery parameters are selected based on the specific anatomical location within the GI tract, such as esophageal, gastric, duodenal or colonic regions, to tailor treatment efficacy and safety. In several aspects, the delivery of electric pulses using the protocols or schemes described herein facilitates enhanced delivery of hemostatic agents or materials (e.g., coagulative or occlusive agents or materials) and / or otherwise speeds up a process of achieving hemostasis. Hemostatic agents may include factor concentrators, mucoadhesive agents, and / or procoagulant suppiementors. Hemostatic agents may include, for example, fibrin, local thrombin, collagen, adrenaline, or hemostats. In some instances, hemostatic agents or materials are not delivered in conjunction with the electric field pulses because they are not necessary.

[0307] In accordance with several examples, the drive circuit includes an opto-isolated pulse control unit which is operated to prevent unintended voltage transfer to low-voltage control electronics, thereby enhancing operational safety. In some examples, the procedure is performed with pulse sequences totalling at least 20 seconds, thereby enabling faster treatment for patients with acute GI bleeding or other internal bleeding.

[0308] The pulse configuration includes (in accordance with several examples) monopolar or bipolar modes that are adjusted depending on the tissue impedance and specific GI tract requirements, thereby enabling versatile treatment across different GI bleeding sources.

[0309] In some examples, the apparatus, device or system of any example described herein is used to perform a method for treating bleeding (e.g., GI bleeding and / or other internal bleeding) in a patient, comprising: positioning one or more electroporation device electrodes at the bleeding site within the patient (e.g., within the GI tract), delivering a primary group of electroporation-type pulses to induce cell membrane permeabilization near the electrodes, subsequently delivering a secondary group of lower-voltage pulses to induce electrophoresis in the target tissue, and repeating the delivery of the primary and secondary pulse groups in a controlled sequence to achieve haemostasis, wherein the method reduces (e.g., minimizes) joule heating, thereby reducing the need for external cooling.

[0310] In some examples, the primary group of pulses is delivered at a field strength in the range of 100 V / cm to 1500 V / cm (e.g., 100 V / cm to 400 V / cm, 200 V / cm to 600 V / cm, 500 V / cm to 1000 V / cm, 800 V / cm to 1500 V / cm, overlapping ranges thereof, or any value within the recited ranges) to create temporary cell pores without causing significant or appreciable thermal damage to adjacent tissue.

[0311] The use may comprise adjusting the pulse parameters, including amplitude, frequency, and pulse duration, based on the tissue impedance measurements obtained during the procedure, to ensure effective bleeding control while reducing (e.g., minimizing) collateral tissue impact.

[0312] Methods of operation include controlling bleeding (e.g., in the gastrointestinal tract, brain or other locations), comprising: administering a series of high-frequency, short-duration electroporationtype pulses to the bleeding site to open cell membranes, applying a sequence of lower-voltage, prolonged pulses following the high-frequency pulses to induce non-thermal cell death, and repeating the pulse sequence for a predetermined number of cycles, wherein the bleeding is controlled rapidly, allowing for completion of the procedure in less than 1 minute.

[0313] In accordance with several examples, the treatment electrodes are inserted endoscopically to a location within the patient (e.g., the GI tract), and the procedure is performed without the need for general anaesthesia, thereby advantageously enabling treatment in an emergency department or outpatient setting.

[0314] The systems, devices and methods described herein may be used to achieve haemostasis in GI tissues or other patient tissues. The methods may include delivering a reversible electroporation pulse group to initiate pore formation in target cells at the bleeding site, delivering an electrophoretic pulse group of lower voltage to promote ion loss and cell destabilization, and cycling the reversible and electrophoretic pulse groups to create a cumulative non-thermal cell death effect, thereby achieving rapid haemostasis while preserving surrounding tissue integrity.

[0315] The method may include selecting pulse parameters based on the location of bleeding (e.g., within the GI tract), where field strength, pulse duration, and / or pulse intervals are selected (e.g., optimized) for tissue thickness and vascularity in specific regions, such as the esophagus, stomach, duodenum or colon.

[0316] The method may be for treating acute GI bleeding, with the method comprising inserting a treatment probe with at least two electrodes into the GI tract near the bleeding source, delivering a sequence of alternating high and low voltage pulses, with the high voltage pulses inducing reversible electroporation and the low voltage pulses inducing non-electroporative, non-thermal, cell death, modulating the pulse frequency and amplitude to reduce (e.g., minimize) patient discomfort. The method may thereby provide effective, minimally invasive haemostasis suitable for emergency intervention.

[0317] In accordance with several examples, the pulses may be delivered in a manner that achieves non- electroporative, non-thermal, cell death at reduced voltage levels compared to traditional methods, thereby reducing the risk of thermal damage in GI tissues.

[0318] In accordance with several examples, a method for managing bleeding (e.g., gastrointestinal and / or other internal bleeding) includes configuring an apparatus (e.g., generator) to deliver a first set of pulses to create reversible electroporation pores in the cells at the bleeding site, delivering a secondary set of pulses at a lower energy level to induce irreversible electroporation without damaging the extracellular matrix, and completing the treatment within a time period of less than 5 minutes, thereby enabling the overall treatment (e.g., procedure) to be conducted by nonspecialist medical personnel in emergency or outpatient settings.

[0319] It will be appreciated that several embodiments employ reversible electroporation and electrophoresis as complementary pulse groups to enable precise tissue ablation without excessive heating. For example, the reversible electroporation, higher-voltage, pulses create temporary or permanent nanopores in cell membranes, allowing ions and molecules to flow across the membrane and, in some cases, triggering cell death. The electrophoresis group of pulses, on the other hand, causes movement of charged particles, such as ions. By introducing lower-voltage, electrophoretic pulses following electroporation, several embodiments enhance ion movement across the newly formed cell pores. This combined approach creates a targeted ion imbalance within the cells, amplifying the cell-killing effect without relying on heat.

[0320] In many cases, the level of discomfort is greatly reduced because the reversible electroporation group creates pores in cell membranes of the treated tissue, following which the electrophoretic group of pulses move ions through these pores, creating a controlled ionic imbalance within cells. This combination aids in effective, targeted cell ablation to achieve haemostasis while reducing (e.g., minimizing) thermal damage, which is especially valuable in treatments involving sensitive tissues, such as in the gastrointestinal tract or cardiac anatomy.

[0321] In accordance with several embodiments, the repetition of the cycles is controlled to keep the tissue temperature below a level such as 80 °C, 70 °C, 60 °C, or 50 °C (or any value within the range from 50 °C to 80 °C).

[0322] In accordance with several embodiments, the high frequency pulses, when delivered to achieve cell death, increase the temperature of the tissue rapidly. In an example, 6 ms of energized on-time increases the tissue temperature by 0.3 °C. Typically, to achieve ablation by irreversible electroporation, literature would suggest that 100 ms+ of energized on-time is required.

[0323] We have also found that there is about a 1 °C decrease for every 1 second of a delay where pulsing does not occur.

[0324] The introduction of the low voltage drive circuitry in the devices and systems described herein, and the ability to switch between high-voltage and low-voltage delivery rapidly, enables the pulse scheme (invention method) described herein.

[0325] In some examples, the Low Voltage pulses do not increase the temperature of the tissue (e.g., low voltage, low current so Joule heating is negligible).

[0326] By implementing the high-voltage / low-voltage switching scheme in the device, the invention method pulse scheme described herein may be performed.

[0327] In accordance with several embodiments, 50° C is the preferred target maximum tissue temperature. For example, thermal damage may begin at temperatures higher than 42° C, but only for prolonged exposures. Thermal damage may be relatively low until 60° C, at which the rate of damage dramatically increases.

[0328] Systems, Devices and Methods for Treating Cardiac Conditions

[0329] Systems, devices and methods (e.g., pulse parameters, protocols, schemes) described herein (e.g., the ERASE protocol) may be used for treating one or more cardiac conditions (e.g., cardiac arrythmias, such as atrial fibrillation). For example, the delivery or application of a primary group of pulses with certain pulse parameters (e.g., higher voltage amplitude, a certain pulse length or width, a certain duration, a certain phase type, a certain frequency) to open cell membranes and a secondary group of pulses with certain pulse parameters (e.g., lower voltage amplitude, a certain pulse length or width, a certain duration, a certain phase type, a certain frequency) to further enlarge the open cell membranes through electrophoresis to cause non-thermal cell death may be provided. The groups of pulses may be repeated for multiple cycles for a total duration time sufficient to treat the cardiac condition, which may be a shorter duration than conventional treatment.

[0330] Systems, Devices and Methods for Treating Diabetes

[0331] Systems, devices and methods (e.g., pulse parameters, protocols, schemes) described herein (e.g., the ERASE protocol) may be used for treating metabolic conditions (e.g., diabetes, such as Type 1 or Type 2 diabetes) or obesity. For example, the delivery or application of a primary group of pulses with certain pulse parameters (e.g., higher voltage amplitude, a certain pulse length or width, a certain duration, a certain phase type, a certain frequency) to open (e.g., prime) cell membranes and a secondary group of pulses with certain pulse parameters (e.g., lower voltage amplitude, a certain pulse length or width, a certain duration, a certain phase type, a certain frequency) to further enlarge the open cell membranes through electrophoresis (e.g., drawing out of ions) to cause non-thermal cell death may be provided. The groups of pulses may be repeated for multiple cycles for a total duration time sufficient to treat the diabetes or obesity or symptoms associated therewith, which may be a shorter duration than conventional treatment.

[0332] The treatment may involve duodenal mucosal resurfacing caused by the pulsed electric field (e.g., electric pulse) delivery. The pulsed electric field (e.g., electric pulse) delivery may cause resurfacing or recellularization of the intestinal lining without generating appreciable heat to cause collateral damage to adjacent tissue. In some embodiments, the treatment may involve nonpref erential or non-fractional delivery of energy (e.g., may not involve selectively targeting or other targeted treatment of certain types of tissue or certain regions of tissue of the duodenum, such as crypts of the mucosa). The duodenal resurfacing may be permanent or temporary. In some embodiments, the duodenal resurfacing or recellularization is initiated hours or days after the treatment or procedure (e.g., after 12 hours, after 24 hours, after 2 days, after 3 days, after 7 days) and is not fully complete until after days or weeks after the treatment or procedure (e.g., after 21 days, after 30 days, after 40 days, after 42 days).

[0333] The treatment may not involve duodenal mucosal resurfacing but instead may cause non-thermal, non-IRE electroporative, cell death of the cells lining the intestine, which may result in regeneration or new cell growth to replace the ablated cells. The new regenerated cells may advantageously improve nutrient absorption and reduce symptoms associated with diabetes (e.g., insulin resistance, hyperinsulinemia, and blood glucose levels). The new regenerated cells may start growing hours, days or weeks after the therapy.

[0334] In accordance with several embodiments, the pulse parameters for treatment of diabetes or obesity or symptoms associated therewith may include the parameters (e.g., voltages, frequencies, pulse widths, durations, repeated bursts, sequences, and / or cycles) described herein.

[0335] The treatment probe or catheter 50 may be advanced to a first treatment location within a portion of a duodenum. The expandable element (e.g., electrode basket 53) may be allowed to self-expand to conform to a diameter of the duodenum at the first treatment location. Treatment may be applied to the first treatment location using the pulse protocols described herein. The applied treatment pulse protocol may provide circumferential ablation at a desired depth at the first treatment location. In some embodiments, the treatment probe or catheter may be advanced to a second treatment location (either with the expandable element still expanded or after re-sheathing the expandable element to cause it to be compressed within the sheath) and treatment may be applied to the second treatment location using the pulse protocols described herein. This process may be repeated for multiple additional treatment locations along the length of the duodenum, jejunum and / or ileum.

[0336] In accordance with several embodiments, the treatment probe or catheter 50 may be controlled robotically by a robotic navigation system. The robotic navigation system may operate in conjunction with the Al and / or ML algorithms describe herein to facilitate automated or semiautomated treatment under clinician supervision.

[0337] Additional Test Results, Features, and Advantages

[0338] Preclinical Validation

[0339] OVERVIEW

[0340] Studies carried out by the Applicant have demonstrated:

[0341] Full-thickness ablation with preserved extracellular matrix Minimal post-procedure inflammation Consistent lesion formation across multiple GI sites Excellent procedural workflow in large-animal models.

[0342] Embodiments of the invention described herein have been performed endoscopically in 4 dogs with advanced colorectal cancer under compassionate oncology use in Ireland. Excellent safety and efficacy outcomes have been observed.

[0343] It is our understanding that IRE has demonstrated that non-thermal ablation can match or exceed the efficacy of thermal methods such as radiofrequency or cryoablation, while offering superior safety for delicate anatomy. Several embodiments of the invention advance this further; delivering rapid, precisely controlled, minimally inflammatory ablation with broad applicability in oncology, metabolic disease, obesity treatment, and beyond.

[0344] Studies were conducted in three pigs; the study evaluated safety and effectiveness across the oesophagus, stomach, duodenum, colon, and rectum. The mechanism of embodiments of the invention have delivered consistent, full-thickness ablation comparable to IRE, but has the major difference in efficiency: treatments were completed in under 45 seconds with minimal thermal rise (<8 °C), eliminating the need for irrigation or pauses to dissipate heat.

[0345] Histological assessment confirmed uniform, well-demarcated mucosal and submucosal ablation across all GI segments, with preservation of extracellular architecture and no evidence of perforation. Duodenal lesions showed complete full-thickness mucosal ablation, gastric and colorectal tissues demonstrated controlled depth and reproducibility, and oesophageal sections revealed precise mucosal ablation with sparing of underlying muscle — validating our novel parameters precision even in thin-walled anatomy. In some embodiments, the lesions have a substantially elliptical shape. In some embodiments, the lesions are strawberry shaped.

[0346] Importantly, these results confirmed that every design objective we set for an optimal PEF ablation system was achieved: no thermal damage, outpatient feasibility, low-cost scalable hardware, and primarily apoptotic cell death — all delivered within treatment times of less than one minute.

[0347] A preclinical study was performed with six treatments performed (four in the duodenum, two in the oesophagus).

[0348] Histological evaluation at both 24 and 72 hours confirmed that the apparatus electrode achieved consistent, full-thickness mucosal and submucosal ablation across treated GI segments, with preserved extracellular matrix, no evidence of perforation, and early reparative changes visible by 72 hours.

[0349] This describes preclinical testing performed to establish safety and efficacy of electrophoretic ablation parameters for gastrointestinal tract applications. Testing was conducted in two phases using porcine models.

[0350] Phase 1 utilized high-frequency irreversible electroporation (H-FIRE) to establish baseline safety and efficacy. Phase 2 involved an approach of the invention, reversible electroporation followed by electrophoretic pulses to achieve equivalent tissue effects with superior thermal control and significantly reduced total energy delivery.

[0351] STUDY OBJECTIVES

[0352] Establish baseline safety and efficacy using high-frequency irreversible electroporation (“H- FIRE”)

[0353] Develop and validate optimized electrophoretic ablation parameters

[0354] Demonstrate equivalence with improved thermal profile

[0355] Confirm non-thermal mechanism of action through histological analysis

[0356] Quantify and compare energy delivery between approaches

[0357] ELECTROPORATION MECHANISMS

[0358] A. Hi h-Frequency Irreversible Electroporation (H-FIRE)

[0359] H-FIRE delivers high-voltage, high-frequency pulses that create permanent (irreversible) disruption of cell membranes, leading to cell death through loss of cellular homeostasis. The mechanism relies on sustained membrane permeabilization that cells cannot repair, resulting in ablation.

[0360] B. Reversible Electroporation

[0361] Reversible electroporation creates temporary membrane permeabilization using similar pulse parameters to H-FIRE but with controlled delivery that allows cellular recovery. While individual pulses may be similar in structure, the overall treatment protocol results in temporary rather than permanent membrane disruption. C. Electrophoretic Effect

[0362] Low-voltage biphasic pulses create electrophoretic movement of charged molecules and ions through permeabilized membranes. When combined with reversible electroporation, this creates controlled tissue effects through electrophoretic mechanisms rather than irreversible membrane disruption, as described above for the invention.

[0363] II. ANIMAL MODEL

[0364] Species: Sus scrofa domesticus (domestic pig)

[0365] Rationale: Porcine gastrointestinal tract provides anatomically and physiologically relevant model for human GI applications

[0366] Sample Size: 3 animals per study phase (n=3)

[0367] PHASE 1 : BASELINE H-FIRE STUDY (START STUDY)

[0368] Study Design

[0369] Treatment modality: High-frequency irreversible electroporation (H-FIRE)

[0370] Anatomical target: Full gastrointestinal tract

[0371] Irrigation: Required for thermal management

[0372] Table 1 : Phase 1 H-FIRE Parameter Ranges

[0373] Table 2: Phase 1 Thermal Profile Table 3: Phase 1 Safety and Efficacy Outcomes

[0374] PHASE 2: OPTIMIZED ELECTROPHORETIC ABLATION STUDY ACCORDING TO THE INVENTION Study Design

[0375] Treatment modality: Electrophoretic ablation (two-phase energy delivery combining reversible electroporation with electrophoretic pulses)

[0376] Anatomical target: Full gastrointestinal tract

[0377] Irrigation: Evaluated for necessity

[0378] Electrophoretic Ablation Protocol

[0379] The electrophoretic ablation protocol consists of two sequential phases that are repeated multiple times depending on the parameter set. This approach utilizes reversible electroporation combined with electrophoretic pulses rather than irreversible electroporation alone. Each complete treatment cycle includes:

[0380] Table 4A: Reversible Electroporation Component - Detailed Parameters Table 4B: Electrophoretic Component - Detailed Parameters

[0381] Table 4C: Energy Delivery in Tests According to the Invention

[0382] Note: These energy levels are all much lower then the 1080J energy level of the Phase 1 Baselein. Energy calculations based on tissue impedance of 100Q. Actual energy delivery may vary with tissue impedance changes during treatment (typical range 50-150Q). Rev. EP = Reversible Electroporation; EP = Electrophoretic.

[0383] Table 5: Phase 2 Thermal Profile Comparison Table 6: Phase 2 Ablation Characteristics

[0384] Table 7: Phase 2 Safety and Efficacy Outcomes COMPARATIVE ANALYSIS

[0385] Energy Efficiency Comparison

[0386] A key finding of this study is the dramatic reduction in total energy delivery required to achieve equivalent histological outcomes. The electrophoretic ablation approach utilizing reversible electroporation combined with electrophoretic pulses achieved the same tissue effects as H-FIRE alone while requiring 66-83% less total energy. Table 8: Energy Delivery Comparison

[0387] Note: Energy calculations at 100Q tissue impedance. Rev. EP = Reversible Electroporation; EP = Electrophoretic. The electrophoretic ablation approach achieved equivalent histological outcomes with 66-83% reduction in total energy delivery.

[0388] The preclinical testing program successfully demonstrated the following:

[0389] MECHANISM EQUIVALENCE: Electrophoretic ablation utilizing reversible electroporation combined with electrophoretic pulses produced histological outcomes equivalent to irreversible electroporation (H-FIRE) alone.

[0390] ENERGY REDUCTION: EPA approach (185-370J) achieved equivalent outcomes with 66-83% less total energy compared to H-FIRE (l,080J).

[0391] IMPROVED THERMAL PROFILE: Peak temperatures reduced from 90°C to <50°C, representing >40°C improvement in thermal control.

[0392] SAFETY: No adverse events observed across full GI tract treatment in either study phase (n=6 animals total).

[0393] NON-THERMAL MECHANISM: Histological analysis confirmed non-thermal cell death mechanism in both approaches.

[0394] REPRODUCIBILITY: Triplicate treatments demonstrated consistent, reproducible outcomes.

[0395] CLINICAL FEASIBILITY: Reduced thermal profile and lower energy requirements suggest potential for reduced irrigation requirements and improved safety margins in clinical application. NOVEL TWO-PHASE APPROACH: The combination of reversible electroporation (temporary membrane permeabilization) followed by electrophoretic pulses (ion movement through permeabilized membranes) represents a fundamentally different mechanism from irreversible electroporation while achieving equivalent tissue effects.

[0396] Several embodiments achieve very effective electrophoretic ablation with minimal risk of patient discomfort and / or have one or more of the following benefits:

[0397] - Lower voltage than traditional IRE

[0398] - Lower voltage than HFIRE (high frequency IRE).

[0399] - Simpler generator required - reduces complexity, cost

[0400] - Quicker procedure than H-FIRE with the same ablation effects

[0401] - Removes drug

[0402] - Makes clinical procedure easier

[0403] - Lower risk of pain

[0404] - No muscle relaxants required

[0405] - Can increase ablation zones

[0406] - Non-thermal

[0407] - Can be performed as an outpatient treatment without general anesthesia

[0408] - Does not require irrigation or cooling techniques

[0409] - Depth control across tissue types with single electrode design

[0410] Changes and modifications in the embodiments described herein can be carried out without departing from the principles of the present disclosure. For example, it is envisaged that there may be additional pulses, especially low voltage pulses applied before the primary (electroporation) group, as this might provide conditioning of the tissue to assist opening of the pores.

[0411] Also, it is envisaged that the apparatus may include a vacuum system to assist guiding and holding the tissue for treatment. An example is described in US9,272,138 the contents of which are incorporated herein by reference.

[0412] The term “embodiment” should not necessarily be interpreted as being covered by a claim but can be a non-limiting example. Each of the disclosed embodiments, aspects, configurations, implementations, and examples of the disclosure may be considered individually or in combination with other embodiments, aspects, examples, configurations, implementations, and variations of the disclosure.

[0413] While the methods, devices and systems described herein may be susceptible to various modifications and alternative forms, specific examples thereof have been shown in the drawings and are herein described in detail. Embodiments are not to be limited to the particular forms or methods disclosed, but rather intended is to cover modifications, equivalents, and alternatives falling within the spirit and scope of the various examples and embodiments described herein and / or in the claims. Further, the disclosure herein of any particular feature, aspect, method, property, characteristic, quality, attribute, element, or the like in connection with an example can be used in all other examples and embodiments set forth herein. Features which are described in the context of separate aspects and embodiments may be used together and / or be interchangeable. Similarly, features described in the context of a single embodiment may also be provided separately or in any suitable sub-combination. In addition, unless otherwise specified, none of the steps of the methods of the present disclosure are confined to any particular order of performance. Any methods disclosed herein need not be performed in the order recited. The use of sequential, or time-ordered language, such as “then,” “next,” “after,” “subsequently,” and the like, unless specifically stated otherwise, or otherwise understood within the context as used, is generally intended to facilitate the flow of the text and is not intended to limit the sequence of operations performed. Thus, some examples may be performed using the sequence of operations described herein, while other examples may be performed following a different sequence of operations.

[0414] Each of the processes, methods, and algorithms described in the preceding sections may be embodied in, and fully or partially automated by, code modules executed by one or more computer systems or computer processors comprising computer hardware. The code modules may be stored on any type of non-transitory computer-readable medium or computer storage device, such as hard drives, solid state memory, optical disc, and / or the like. The systems and modules may also be transmitted as generated data signals (for example, as part of a carrier wave or other analog or digital propagated signal) on a variety of computer-readable transmission mediums, including wireless-based and wired / cable-based mediums, and may take a variety of forms (for example, as part of a single or multiplexed analog signal, or as multiple discrete digital packets or frames). The processes and algorithms may be implemented partially or wholly in application-specific circuitry. The results of the disclosed processes and process steps may be stored, persistently or otherwise, in any type of non-transitory computer storage such as, for example, volatile or non-volatile storage. Any process descriptions, elements, or blocks in the flow diagrams described herein and / or depicted in the attached figures should be understood as potentially representing modules, segments, or portions of code which include one or more executable instructions for implementing specific logical functions or steps in the process. Alternate implementations are included within the scope of the embodiments described herein in which elements or functions may be deleted, executed out of order from that shown or discussed, including substantially concurrently or in reverse order, depending on the functionality involved, as would be understood by those skilled in the art.

[0415] All of the methods and processes described above may be embodied in, and partially or fully automated via, software code modules executed by one or more general purpose computers. For example, the methods described herein may be performed by one or more processors or microcontrollers of the controller described herein. The methods may be executed on the one or more processors or microcontrollers in response to execution of software instructions or other executable code read from a tangible computer readable medium. A tangible computer readable medium is a data storage device that can store data that is readable by a computer system. Examples of computer readable mediums include read-only memory, random-access memory, other volatile or non-volatile memory devices, CD-ROMs, magnetic tape, flash drives, and optical data storage devices.

[0416] Conditional language used herein, such as, among others, “can,” “might,” “may,” “e.g.,” and the like, unless specifically stated otherwise, or otherwise understood within the context as used, is generally intended to convey that some examples include, while other examples do not include, certain features, elements, and / or states. Thus, such conditional language is not generally intended to imply that features, elements, blocks, and / or states are in any way required for one or more examples or that one or more examples necessarily include logic for deciding, with or without author input or prompting, whether these features, elements and / or states are included or are to be performed in any particular example. Where devices or methods “comprise” certain features or steps, such devices or methods may also “consist essentially of’ such features or steps if identified as such in the claims. Where devices or methods “comprise” certain features or steps, such devices or methods may also “consist” of such features or steps if identified as such in the claims. The terms “comprising,” “including,” “having,” and the like are synonymous and are used inclusively, in an open- ended fashion, and do not exclude additional elements, features, acts, operations, and so forth. In addition, the term “or” is used in its inclusive sense (and not in its exclusive sense) so that when used, for example, to connect a list of elements, the term “or” means one, some, or all of the elements in the list. In addition, the articles “a,” “an,” and “the” as used in this application and the appended claims are to be construed to mean “one or more” or “at least one” unless specified otherwise.

[0417] The methods disclosed herein may include certain actions taken by a practitioner; however, the methods can also include any user or third-party instruction of those actions, either expressly or by implication. For example, actions such as “positioning a device” include “instructing positioning of a device.”

[0418] The ranges disclosed herein also encompass any and all overlap, sub-ranges, and combinations thereof. The section headings used herein are merely provided to enhance readability and are not intended to limit the scope of the embodiments disclosed in a particular section to the features or elements disclosed in that section. Language such as “up to,” “at least,” “greater than,” “less than,” “between,” and the like includes the number recited. Numbers preceded by a term such as “about” or “approximately” include the recited numbers and should be interpreted based on the circumstances (e.g., as accurate as reasonable under the circumstances, for example ±5%, ±10%, ±15%, etc.). For example, “about 1 degree Celsius” includes “1 degree Celsius.” Phrases preceded by a term such as “substantially” include the recited phrase and should be interpreted based on the circumstances (e.g., as much as reasonably possible under the circumstances). For example, “substantially linear” includes “linear.” Unless stated otherwise, all measurements are at standard conditions including temperature and pressure. The phrase “at least one of’ is intended to require at least one item from the subsequent listing, not one type of each item from each item in the subsequent listing. For example, “at least one of A, B, and C” can include A; B; C; A and B; A and C; B and C; or A, B, and C.

Claims

Claims1. An apparatus for treating one or more metabolic conditions of a subject, the apparatus comprising: a controller, a drive circuit controlled by the controller to generate electric pulses, and a probe comprising at least two electrodes or electrode portions electrically coupled to the drive circuit for delivering the electric pulses, wherein the controller is configured to cause the drive circuit to provide electric pulses in:(a) a reversible electroporation group of pulses sufficient to open cell pores, wherein at least some of the reversible electroporation group of pulses provide a field strength in the range of 100 V / cm to 1500 V / cm;(b) a secondary group of one or more electrophoretic pulses, wherein the secondary group of one or more electrophoretic pulses have a field strength in the range of 1 V / cm to 100 V / cm; and(c) repetition of the reversible electroporation group of pulses and the secondary group of one or more electrophoretic pulses in N cycles, N having a value of 1 to 50, so that the cells of the duodenum surface at the treatment site experience non-thermal cell death.

2. An apparatus of claim 1, wherein the field strength of the reversible electroporation group of pulses is 1000 V / cm or less, wherein the field strength of the secondary group of one or more electrophoretic pulses is between 20 V / cm and 70 V / cm, wherein the reversible electroporation group of pulses and the one or more electrophoretic pulses each comprise biphasic pulses, and wherein N has a value less than 20.

3. An apparatus of claim 2, wherein a pulse width of the reversible electroporation group of pulses is between 1 and 5 microseconds and wherein a pulse width of the one or more electrophoretic pulses is between 20 and 200 milliseconds.

4. An apparatus of claim 2 or claim 3, wherein the reversible electroporation group of pulses comprises multiple bursts of pulses prior to the secondary group of one or more electrophoretic pulses.

5. An apparatus of any one of claims 1 to 4, wherein the field strength of the one or more electrophoretic pulses is lower than the field strength of the reversible electroporation group of pulses.

6. An apparatus of any one of claims 1 to 4, wherein the subject has been determined to have grown tolerant to one or more GLP-1 agonists or semaglutides over a determined period of time.

7. An apparatus of any one of claims 1 to 4, wherein the subject has been determined to be sufficiently responsive to one or more GLP-1 agonists or semaglutides over a determined period of time.

8. An apparatus of any one of claims 1 to 7, wherein the probe comprises a single expandable electrode basket comprising spacers positioned along wires of the expandable electrode basket so as to electrically isolate a first portion and a second portion of the expandable electrode basket, with the first portion configured to act as a positive electrode terminal and the second portion configured to act as a negative electrode terminal, thereby forming a bipolar electrode.

9. An apparatus of claim 8, wherein the wires of the expandable electrode basket are formed of a shape memory material such that the expandable electrode basket is self-expandable and configured to conform to various dimensions along a length of the duodenum.

10. An apparatus of claim 8, wherein at least a portion of the expandable electrode basket is configured to circumferentially contact a luminal surface of the duodenum.

11. An apparatus of claim 8, wherein the spacers are configured to maintain a uniform spacing between the first portion and the second portion of the expandable electrode basket regardless of an extent of expansion of the expandable electrode basket.

12. An apparatus of claim 11, further comprising one or more algorithms stored in memory of the controller that are configured to alter the value of N to control a depth of a treatment zone formed by the electric pulses.

13. An apparatus of any one of the preceding claims, wherein the one or more metabolic conditions comprise one or more of diabetes or obesity.

14. An electroporation apparatus for use in the treatment of a treatment site such as a bleeding site, the apparatus comprising a controller (2), a drive circuit (7) controlled by the controller to generate drive pulses, and at least two electrodes (53, 54) linked with the drive circuit for delivering the pulses, wherein the controller is configured to cause the drive circuit to provide pulses in:(a) a reversible electroporation group of pulses (60) sufficient to create / open cell pores and / or disrupt cell membranes of tissue near the electrodes, wherein at least some of the (a) group of pulses provide a field strength in the range of 100 V / cm to 2500 V / cm;(b) a secondary group of one or more pulses (65) at least some of which have lower voltages than pulses of the group (a), wherein the group (b) of pulses includes pulses having a field strength in the range of 1 V / cm to 100 V / cm; and(c) repetition of (a) and (b) in N cycles, N having a value of 0 to 100.

15. An apparatus as claimed in claim 14, wherein the group (b) of pulses include pulses having parameters to induce a stress on the cell membrane, enlarging the cell pores from the group (a) and to facilitate electrophoresis within the tissue, accelerating the loss of ions from the electroporated cells, reducing the capacity for recovery and triggering non-thermal cell death.

16. An apparatus as claimed in claim 15, wherein at least some of said (b) group of pulses have parameters to trigger cell death without destruction of an extracellular matrix.

17. An apparatus as claimed in any of claims 14 to 16, wherein the (a) group comprises a series of M bursts of pulses, each burst having a plurality of pulses.

18. An apparatus as claimed in any of claims 14 to 17, wherein at least some of the (a) group comprises bipolar / biphasic pulses, and optionally the controller is configured to cause the at least some pulses in the secondary group to be biphasic pulses to further reduce heating during treatment.

19. An apparatus as claimed in any of claims 14 to 18, wherein at least some of the (a) group of pulses have a field strength in the range of 100 V / cm to 2500 V / cm.

20. An apparatus as claimed in claim 19, wherein at least some of the (a) group of pulses have a field strength in the range of 350 V / cm to 1500 V / cm or 400 V / cm to 1300 V / cm.

21. An apparatus as claimed in claim 20, wherein said field strength is in the range of 400 V / cm to 1100 V / cm.

22. An apparatus as claimed in any of claims 14 to 21, wherein at least some of the (a) group of pulses each have a pulse length in the range of 0.1 ps to 10 ms.

23. An apparatus as claimed in claim 22, wherein at least some of the (a) group of pulses each 10 have a pulse length in the range of 0.1 ps to 1 ms.

24. An apparatus as claimed in claim 23, wherein at least some of the (a) group of pulses each have a pulse length in the range of 1 ps to 5 ps.

25. An apparatus as claimed in any of claims 14 to 24, wherein at least some of the (a) group of pulses are provided in bursts of pulses separated by time delays which are greater than time delays between individual pulses, and at least some bursts each have a duration in the range of 0.1 ms to 1000 ms.

26. An apparatus as claimed in claim 25, wherein said duration is in the range of 0.1 ms to 5 ms or 0.2 ms to 5 ms.

27. An apparatus as claimed in any of claims 14 to 26, wherein at least some of the (a) group of pulses are provided in bursts of pulses separated by time delays which are greater than time delays between individual pulses, and the number of bursts in each cycle is in the range of 1 to 1000.

28. An apparatus as claimed in claim 27, wherein said number is in the range of 5 to 50.

29. An apparatus as claimed in any of claims 14 to 28, wherein the group (b) of pulses includes pulses having a field strength in the range of 1 V / cm to 100 V / cm.

30. An apparatus as claimed in any of claims 14 to 29, wherein at least some of the group (b) of pulses include pulses which are square wave monophasic pulses of positive or negative polarity.

31. An apparatus as claimed in any of claims 14 to 30, wherein at least some of the group (b) of pulses include at least one pulse having a length in the range of 10 ms to 1000 ms.

32. An apparatus as claimed in claim 31, wherein said length is in the range of 100 ms to 1000 ms.

33. An apparatus as claimed in claim 32, wherein said length is in the range of 250 ms to 750 ms.

34. An apparatus as claimed in any of claims 14 to 33, wherein the total time for the treatment is less than one minute.

35. An apparatus as claimed in claim 34, wherein the total time for the treatment is in the range of 6 ms to 20 seconds.

36. An apparatus as claimed in any of claims 14 to 35, wherein the controller is configured to choose the value of N according to a volume of tissue to be treated.

37. An apparatus as claimed in any of claims 14 to 36, wherein the value of N is in the range of 1 to 100.

38. An apparatus as claimed in claim 37, wherein the value of N is in the range of 2 to 10.

39. An apparatus as claimed in claim 38, wherein the value of N is in the range of 2 to 6.

40. An apparatus as claimed in any of claims 14 to 39, wherein the (a) group has a total energised time in the range of 5 ms to 20 ms for each cycle.

41. An apparatus as claimed in any of claims 14 to 40, wherein the controller is configured to set the value of N and / or the voltage levels for the steps (a) and (b) in order to maintain a tissue temperature below 80 °C, preferably below 70 °C, more preferably below 60 °C.

42. An apparatus as claimed in claim 41, further comprising a temperature sensor for detecting or estimating temperature of tissue being treated and the controller is configured to automatically set the value of N and / or the voltage levels for the steps (a) and (b) in order to maintain a tissue temperature below 80 °C, preferably below 70 °C, more preferably below 60 °C.

43. An apparatus of claim 42, wherein the controller is configured to cause the primary group of pulses to comprises a series of pulses with a field strength in the range of 100 V / cm to 2500 V / cm, tailored to achieve reversible electroporation and minimize collateral tissue damage in the GI tract.

44. An apparatus of any of claims 14 to 43, wherein the controller is configured to cause the secondary group of pulses to include parameters that induce stress on the cell membrane, enlarging the pores created by the primary group and promoting electrophoresis within the tissue, facilitating irreversible cell death without the destruction of the extracellular matrix.

45. An apparatus of any of claims 14 to 44, wherein the controller is configured to cause at least some pulses in the primary group to be biphasic pulses to further reduce heating during treatment.

46. An apparatus of any of claims 14 to 45, wherein the controller is configured to cause the at least some pulses in the secondary group to be biphasic pulses to further reduce heating during treatment.

47. An apparatus of any of claims 14 to 46, wherein the apparatus comprises a handheld housing and an electrode assembly configured for endoscopic or laparoscopic insertion.

48. An apparatus of any of claims 14 to 47, wherein the apparatus further comprises a user interface connected to the controller, wherein the user interface is configured to allow an operator to adjust the values of N and pulse parameters according to the volume and characteristics of target GI tissue.

49. An apparatus of any of claims 14 to 48, wherein the apparatus further comprises a pulse modulation system, and said system is configured to adjust the amplitude, duration, and polarity of each pulse in real time according to feedback of tissue impedance, allowing for adaptive control to prevent overheating.

50. An apparatus of any of claims 14 to 49, wherein the electrodes are arranged on an expandable probe structure, thereby enabling precise positioning within the GI tract and ensuring uniform pulse distribution across the treatment area.

51. An apparatus of any of claims 29 to 50, wherein the drive circuit includes an opto-isolated pulse control unit to prevent unintended voltage transfer to low-voltage control electronic circuits, enhancing operational safety.

52. An apparatus of any of claims 14 to 51, wherein the apparatus is configured to perform the entire procedure with pulse sequences totaling at most 600 seconds for treatment of patients with acute GI bleeding, and: in the group (a) the pulses have a V / cm value in the range 400 to 1300, the pulses are biphasic, and at least some have a duration of 1 ps to 3 ps, and the pulse frequency is in the range of 100 kHz to 260 kHz; in the group (b) the pulses have a V / cm value in the range 25 to 60, the pulses are biphasic, and at least some have a duration of 30 ms 70 ms, and the pulse frequency is in the range of 1 Hz to 100 Hz, and the value of N is in the range of 2 of 10.

53. An electroporation apparatus for inducing non-thermal irreversible electroporation in GI tissues, comprising: a handheld housing, a drive circuit to generate customizable pulse sequences, and an electrode assembly configured for endoscopic or laparoscopic insertion.

54. An electroporation apparatus for use in the treatment of the duodenum to treat metabolic conditions such as Type 2 diabetes, the apparatus comprising: a controller, a drive circuit controlled by the controller to generate electric pulses, anda probe comprising at least two electrodes electrically coupled to the drive circuit for delivering the pulses, wherein the controller is configured to cause the drive circuit to provide pulses in:(a) a reversible electroporation group of pulses sufficient to open cell pores and / or disrupt cell membranes of tissue near the electrodes, wherein at least some of the reversible electroporation group of pulses provide a field strength in the range of 100 V / cm to 2500 V / cm;(b) a secondary group of one or more electrophoretic pulses, at least some of which have lower voltages than pulses of the reversible electroporation group of pulses, wherein the secondary group of pulses includes pulses having a field strength in the range of 1 V / cm to 100 V / cm; and(c) repetition of the reversible electroporation group of pulses and the secondary group of one or more electrophoretic pulses in N cycles, N having a value of 0 to 100, preferably 2 to 20 so that the duodenum surface is reset at the treatment site.

55. An electroporation apparatus for use in the treatment of a tract in a mammal, the apparatus comprising: a controller, a drive circuit controlled by the controller to generate electric pulses, and a probe comprising at least two electrodes electrically coupled to the drive circuit for delivering the pulses, wherein the controller is configured to cause the drive circuit to provide pulses in:(a) a reversible electroporation group of pulses sufficient to open cell pores and / or disrupt cell membranes of tissue near the electrodes, wherein at least some of the reversible electroporation group of pulses provide a field strength in the range of 100 V / cm to 2500 V / cm;(b) a secondary group of one or more electrophoretic pulses, at least some of which have lower voltages than pulses of the reversible electroporation group of pulses, wherein the secondary group of pulses includes pulses having a field strength in the range of 1 V / cm to 100 V / cm; and(c) repetition of the reversible electroporation group of pulses and the secondary group of one or more electrophoretic pulses in N cycles, N having a value of 0 to 100, preferably 2 to 20 so that there is sufficient ablation to improve a condition such as benign prostrate hyperplasia (BPH), bladder cancer, urologic ablation in oncology.

56. Use of an apparatus of any of claims 1 to 55 for the treatment of cardiac conditions, such as arrythmias.

57. Use of an apparatus of any of claims 1 to 55 for the treatment of diabetes.

58. Use of an apparatus of any of claims 1 to 55 for the treatment of bleeding, such as gastrointestinal bleeding.

59. An apparatus for treating a bleeding condition (e.g., gastrointestinal bleeding) as described herein.

60. An apparatus for treating a cardiac condition (e.g., cardiac arrythmia) as described herein.

61. An electroporation apparatus for use in the treatment of bleeding, the apparatus comprising: a controller, a drive circuit controlled by the controller to generate electric pulses, and a probe comprising at least two electrodes electrically coupled to the drive circuit for delivering the pulses, wherein the controller is configured to cause the drive circuit to provide pulses in:(a) a reversible electroporation group of pulses sufficient to open cell pores and / or disrupt cell membranes of tissue near the electrodes, wherein at least some of the reversible electroporation group of pulses provide a field strength in the range of 100 V / cm to 2500 V / cm;(b) a secondary group of one or more electrophoretic pulses, at least some of which have lower voltages than pulses of the reversible electroporation group of pulses, wherein the secondary group of pulses includes pulses having a field strength in the range of 1 V / cm to 100 V / cm; and(c) repetition of the reversible electroporation group of pulses and the secondary group of one or more electrophoretic pulses in N cycles, N having a value of 2 to 20.

62. An apparatus as claimed in claim 61 , wherein the reversible electroporation group of pulses comprise biphasic or bipolar pulses of alternating positive and negative polarity, and optionally the reversible electroporation group of pulses have a pulse width of between 1 ps and 5 ps.

63. An apparatus as claimed in any preceding claim, wherein: the controller is configured to algorithmically control pulse parameters including one or more of number of N value, pulse duration, voltage amplitude, and pulse width to achieve a desired depth of treatment based on a type of tissue and individual patient parameters, the controller is configured to perform said control based on neural networks trained on data collected from multiple patients or anatomies over time using Al or ML techniques applied to medical images of a particular treatment location to identify qualitative or quantitative metrics to identify, distinguish or characterize tissue type and / or to identify boundaries between layers of tissue and in which said models are trained to identify anatomy that would respond well to the therapy of the apparatus.

64. An apparatus as claimed in any of claims 61 to 63, wherein the one or more pulses of the secondary group of electrophoretic pulses have a pulse width of between 0.1 ms and 10 ms.

65. An apparatus as claimed in any preceding claim, wherein the controller comprises digital data processors configured to perform at least some control steps according to trained models such as artificial intelligence Al or machine learning ML trained neural network models, and in which the controller comprises digital data processors and memories located either locally or remotely such as in the Cloud.

66. An apparatus as claimed in claim 65, wherein the models are trained based on collection of data from subjects over a period of time, and the controller is configured to provide pulse protocols according to any one or more of data collection, data analysis, image interrogation and analysis, patient candidate selection or assessment, treatment recommendations and / or predictions.

67. An apparatus as claimed in either of claims 65 or 66, wherein the controller is configured to access a library of data collected from multiple patients over time.

68. An apparatus as claimed in any of claims 65 to 67, wherein the controller is configured to, after a treatment has been performed, capture and anonymize treatment data and upload said data to a cloud computing server or network, and said neural networks are configured to be trained and improved based on said uploaded data.

69. An apparatus as claimed in any of claims 65 to 68, wherein the controller is configured to execute algorithms trained according to said models to identify or segment tissue types or layers, for example to identify or determine various lumen boundaries or layers in images and to calculate diameters or other cross-sectional dimensions or treatment depths based on the lumen boundaries or layers; and preferably the controller is configured to execute said algorithms to recommend portions of length of a lumen to treat and / or the depth of tissue to treat.

70. An apparatus as claimed in any of claims 65 to 69, wherein the controller is configured to use said models to predict treatment outcomes that a particular therapy will be successful for a particular patient based on a variety of factors, and to provide information to a physician to aid in making a diagnosis an / or treatment decision.

71. An apparatus as claimed in any of claims 65 to 70, wherein the controller is configured to determine predictive outcomes based on determinations of one or more co-morbidities associated with a disease or condition such as diabetes or obesity, in which said prediction is performed according to current levels or trends in biomarkers.

72. An apparatus as claimed in any of claims 65 to 71, wherein the apparatus comprises a condition sensor such as a temperature sensor and the controller is configures to use feedback from said sensor or sensors to dynamically adjust pulse drive parameters according to said feedback and said neural network models.

73. An apparatus as claimed in any of claims 65 to 72, wherein the controller is configured to deliver diagnostic test pulses and measure impedance over time to determine a characteristic of a tissue region, and to generate an output for a physician to assist with choice of treatment parameters.

74. An apparatus as claimed in claim 73, wherein the controller is configured to deliver said test pulses in real time and make to generate an output to either aid a physician to adjust parameters in real time or to automatically adjust said parameters in real time.

75. An apparatus comprising a digital storage device library of images and a digital data processor configured to analyze said images using artificial intelligence (Al) or machinelearning (ML) models to generate higher confidence levels in determining vascular morphology or diagnosis, wherein the library optionally comprises data related to one or more of a patient’s age, gender, comorbidities, diet, activity level, genetic predisposition, biomarkers, other images and scans, and other risk enhancing or risk mitigating factors.

76. A kit comprising one or more catheter, and one or more generator or controller executing one or more artificial intelligence (Al) or machine learning models or algorithms as described herein along with instructions for use.

77. Use of any of the apparatus or systems described herein to treat subjects determined to have grown tolerant or resistant to treatment using GLP-1 agonists or semaglutides after a period of time or from initiation of treatment.

78. Use of an apparatus according to any preceding claim, with application of artificial intelligence (Al) to determine patient eligibility or likelihood of favorable response to treatment and additionally use of the apparatus and Al to reduce risk that the subject receives unnecessary further interventions (e.g., if determined that therapy would not be successful based on non-responsiveness of the subject to prior GLP-1 or semaglutide treatment).

79. A method of manufacture of any of the apparatus or devices and systems having one or more of the features described in the foregoing description.

80. A method of treating a bleeding condition (e.g., gastrointestinal bleeding) in a patient as described herein.

81. A method of treating subjects determined to have grown tolerant or resistant to treatment using GLP-1 agonists or semaglutides after a period of time or from initiation of treatment.

82. A method of treating one or more metabolic conditions of a subject, the method comprising:(a) delivering a reversible electroporation group of pulses sufficient to open cell pores along a circumferential portion of a mucosal layer of a duodenum of the subject, wherein at least some of the reversible electroporation group of pulses have a voltage of 100 V to 1500 V;(b) following delivery of the reversible electroporation group of pulses, delivering a secondary group of electrophoretic pulses to the cells along the circumferential portion of the mucosal layer of the duodenum of the subject, wherein the secondary group of electrophoretic pulses have a voltage of 1 V to 100 V; and(c) following delivery of the secondary group of electrophoretic pulses, repeating steps (a) and (b) in a plurality of cycles, wherein after the plurality of cycles, the cells along the circumferential portion of the mucosal layer of the duodenum of the subject experience non-thermal cell death.

83. A method as claimed in claim 82, wherein the voltage of the reversible electroporation group of pulses is 1000 V or less, wherein the voltage of the secondary group of electrophoretic pulses is between 20 V and 70 V, wherein the reversible electroporation group of pulses and the electrophoretic pulses each comprise biphasic pulses, and wherein the plurality of cycles is less than 20.

84. A method as claimed in claim 83, wherein a pulse width of the reversible electroporation group of pulses is between 1 and 5 microseconds and wherein a pulse width of the electrophoretic pulses is between 20 and 200 milliseconds.

85. A method as claimed in claim 84, wherein the reversible electroporation group of pulses comprises multiple bursts of pulses prior to the secondary group of electrophoretic pulses.

86. A method as claimed in any of claims 82 to 85, wherein the voltage of the electrophoretic pulses is lower than the voltage of the reversible electroporation group of pulses.

87. A method as claimed in any of claims 82 to 86, wherein the subject has been determined to have grown tolerant to one or more GLP-1 agonists or semaglutides over a determined period of time.

88. A method as claimed in any of claims 82 to 87, wherein the subject has been determined to be sufficiently responsive to one or more GLP-1 agonists or semaglutides over a determined period of time.

89. A method as claimed in any of claims 82 to 88, wherein the delivery of the reversible electroporation group of pulses and the electrophoretic pulses is provided by a probecomprising a single expandable electrode basket comprising spacers positioned along wires of the expandable electrode basket so as to electrically isolate a first portion and a second portion of the expandable electrode basket, with the first portion configured to act as a positive electrode terminal and the second portion configured to act as a negative electrode terminal, thereby forming a bipolar electrode.

90. A method as claimed in claim 89, wherein the wires of the expandable electrode basket are formed of a shape memory material such that the expandable electrode basket is selfexpandable and configured to conform to various dimensions along a length of the duodenum.

91. A method as claimed in claim 89 or claim 90, wherein at least a portion of the expandable electrode basket is configured to circumferentially contact a luminal surface of the duodenum.

92. A method as claimed in any of claims 89 to 91, wherein the spacers are configured to maintain a uniform spacing between the first portion and the second portion of the expandable electrode basket regardless of an extent of expansion of the expandable electrode basket.

93. A method as claimed in claim 92, further comprising altering the number of cycles to control a depth of a treatment zone formed by the electric pulses.

94. A method as claimed in any one of claims 82 to 93, wherein the one or more metabolic conditions comprise Type 2 diabetes.

95. A method as claimed in any of any one of claims 82 to 94, wherein the one or more metabolic conditions comprise obesity.

96. A method as claimed in any of claims 82 to 95, wherein the one or more metabolic conditions comprise metabolic syndrome.

97. A method as claimed in any of claims 82 to 96, further comprising repeating steps (a) to (c) of claim 72 at one or more additional locations along a length of the duodenum of the subject.

98. A method as claimed in any of claims 82 to 97, further comprising repeating steps (a) to (c) of claim 72 at one or more additional locations within a jejunum of the subject.

99. A method as claimed in any of claims 82 to 98, wherein the method is performed in less than 45 seconds.

100. A method as claimed in any of claims 82 to 89, wherein the method is performed in less than 30 seconds.

101. A method as claimed in any of claims 82 to 100, wherein the cell death of the mucosal layer causes new cells to grow to replace the dead cells over a period of time.

102. A method of treatment of tissue of a mammal, the treatment being carried out with use of a probe having at least two electrodes and a drive circuit controlled by a controller to generate drive pulses, wherein the controller causes the drive circuit to provide pulses in:(a) an electroporation group of pulses sufficient to create / open cell pores and / or disrupt cell membranes of tissue near the electrodes,(b) a secondary group of one or more electrophoretic pulses, and(c) repetition of (a) and (b) in N cycles, N having a value of 0 to 100, wherein the treatment is sufficient to achieve in a mammal one or more selected from: ablation of tissue, such as in the heart or any other organ; or haemostasis, such as in a lumen such as the GI tract or the stomach; or duodenal muocosal resurfacing, such as for a metabolic condition.

103. A method as claimed in claim 102, wherein the controller sets the value of N and / or the voltage levels for the steps (a) and (b) in order to maintain a tissue temperature below 60 °C.

104. A method as claimed in claim 102 or 103, wherein the controller is linked with a temperature sensor for detecting or estimating temperature of tissue being treated and wherein the controller automatically sets the value of N and / or the voltage levels for the steps (a) and (b) in order to maintain a tissue temperature below 60 °C.

105. A method as claimed in any of claims 102 to 104, wherein the group (b) of pulses include pulses having parameters to induce a stress on the cell membrane, enlarging the cell pores from the group (a) and to facilitate electrophoresis within the tissue, accelerating the loss of ions from the electroporated cells, reducing the capacity for recovery and triggering nonthermal cell death.

106. A method as claimed in claim 105, wherein said (b) group of pulses have parameters to trigger cell death without destruction of an extracellular matrix.

107. A method as claimed in any of claims 102 to 106, wherein the tissue is in the duodenum.

108. A method for controlling gastrointestinal (GI) bleeding using an electroporation apparatus with a controller and electrodes, the method comprising: delivering at the electrodes a primary group of pulses to GI tissue to create pores in cell membranes, applying a secondary group of lower- voltage pulses at the electrodes following delivery of the primary group of pulses to enlarge the pores in the cell membranes and to facilitate cell death, and repeating the delivery of the primary group of pulses and the applying of the secondary group of lower-voltage pulses in a controlled number of cycles, wherein the pulse parameters are optimized to minimize tissue heating, thereby allowing effective bleeding control in a GI tract without the need for additional cooling methods.

109. A method as claimed in any of claims 108, wherein the secondary group of pulses includes one or more square-wave monophasic pulses with a pulse length in the range of 10 ms to 1000 ms.

110. A method as claimed in any of claims 102 to 109, wherein the secondary group of pulses includes one or more square-wave biphasic pulses with a pulse length in the range of 10 ms to 1000 ms.

111. A method as claimed in any of claims 102 to 110, wherein the total treatment time is at least one minute, thereby facilitating rapid intervention in emergency care settings.

112. A method as claimed in any of claims 102 to 111, wherein the primary group of pulses includes pulses with pulse lengths ranging from 0.1 ps to 10 ms, optimizing the balance between energy delivery and minimizing thermal effects on GI tissue.

113. A method as claimed in any of claims 102 to 112, wherein the secondary group of pulses is in the range of 1 V / cm to 100 V / cm, ensuring controlled electrophoretic effects while reducing or eliminating the need for fluid cooling.

114. A method as claimed in any of claims 102 to 113, wherein the primary and the secondary pulses are delivered as a sequence of bursts separated by time delays, such that each burst has a duration in the range of 0.1 ms to 1000 ms, to provide sufficient recovery time for the tissue and minimize cumulative heating.

115. A method as claimed in any of claims 102 to 114, wherein the pulse parameters are selected based on a specific anatomical location within the GI tract, such as esophageal, gastric, duodenal or colonic regions, to tailor treatment efficacy and safety.

116. A method as claimed in any of claims 102 to 115, wherein the drive circuit includes an opto-isolated pulse control unit which is operated to prevent unintended voltage transfer to low-voltage control electronic circuits, thereby enhancing operational safety.

117. A method as claimed in any of claims 102 to 116, wherein the procedure comprises pulse sequences totaling no more than 300 seconds, preferably no more than 60 seconds, and more preferably no more than 20 seconds, thereby enabling faster treatment for patients with acute GI bleeding.

118. A method as claimed in any of 102 to 117, wherein the pulse configuration includes monopolar or bipolar modes that are adjusted depending on the tissue impedance and specific GI tract requirements, thereby enabling versatile treatment across different GI bleeding sources.

119. A method for treating tissue in the gastrointestinal (GI) tract, such as bleeding, the method comprising: positioning at least two electrodes at the bleeding site within a GI tract of the patient;delivering a primary group of electroporation pulses to induce cell membrane permeabilization near the electrodes; subsequently delivering a secondary group of lower-voltage pulses to induce electrophoresis in the target tissue; and repeating the delivery of the primary and secondary pulse groups in a controlled sequence to achieve haemostasis and / or ablation, whereby the method minimizes joule heating, thereby reducing a need for external cooling.

120. A method as claimed in any of claims 102 to 119, wherein the primary group of pulses is delivered at a field strength in the range of 100 V / cm to 1500 V / cm to create temporary cell pores without causing significant thermal damage to adjacent tissue.

121. A method as claimed in any of claims 102 to 120, further comprising adjusting the pulse parameters, including amplitude, frequency, and pulse duration, based on tissue impedance measurements obtained during the procedure, to ensure effective bleeding control while minimizing collateral tissue impact.

122. A method for controlling bleeding in the gastrointestinal tract, comprising: administering a series of high-frequency, short-duration electroporation pulses to the bleeding site to open cell membrane; applying a sequence of lower- voltage, prolonged pulses following the high-frequency pulses to induce non-thermal cell death; and repeating the pulse sequence for a predetermined number of cycles, wherein the bleeding is controlled rapidly, allowing for completion of the procedure in less than 30 minutes.

123. A method as claimed in claim 122, wherein the frequency and the duration of the high- frequency pulses is in the range of 100 to 400 kHz and 1 to 5 ps.

124. A method as claimed in claim 122 or claim 123, wherein the electroporation electrodes are inserted endoscopically to the GI tract, and wherein the procedure is preferably performed without general anaesthesia.

125. A method of achieving haemostasis and / or ablation in GI tissues, comprising:delivering a reversible electroporation pulse group to initiate pore formation in target cells at a treatment site such as a bleeding site; delivering an electrophoretic pulse group of lower voltage to promote ion loss and cell destabilization; and cycling the reversible and electrophoretic pulse groups to create a cumulative non-thermal cell death effect, thereby achieving rapid haemostasis and / or ablation while preserving surrounding tissue integrity.

126. A method as claimed in claim 125, further comprising selecting pulse parameters based on the location of the treatment site, where field strength, pulse duration, and pulse intervals are optimized for tissue thickness and vascularity in specific regions, such as the esophagus, stomach, or colon.

127. A method for treating acute gastrointestinal (GI) bleeding, comprising: inserting an electroporation probe with at least two electrodes into a GI tract near the bleeding source; delivering a sequence of alternating high and low voltage pulses, with the high voltage pulses inducing reversible electroporation and the low voltage pulses inducing irreversible electroporation; modulating the pulse frequency and amplitude to minimize patient discomfort, wherein the method provides effective, minimally invasive haemostasis.

128. The method of claim 127, wherein the pulses are delivered in a manner that achieves irreversible electroporation at reduced voltage levels compared to traditional methods, thereby reducing the risk of thermal damage in GI tissues.

129. A method for managing gastrointestinal (GI) bleeding with an electroporation device, the method comprising: configuring the device to deliver a first set of pulses to create electroporation pores in the cells at a bleeding site within a GI tract; delivering a secondary set of pulses at a lower energy level to induce irreversible electroporation without damaging the extracellular matrix; and completing the treatment within a time period of less than 30 minutes, thereby enabling the procedure to be conducted by non-specialist medical personnel in emergency settings.

130. A method of treatment of bleeding in a mammal, the treatment being carried out with use of a probe having at least two electrodes and a drive circuit controlled by a controller to generate drive pulses, wherein the controller causes the drive circuit to provide pulses in:(a) a reversible electroporation group of pulses (60) sufficient to create / open cell pores and / or disrupt cell membranes of tissue near the electrodes, wherein at least some of the (a) group of pulses provide a field strength in the range of 100 V / cm to 2500 V / cm;(b) a secondary group of one or more pulses (65) at least some of which have lower voltages than pulses of the group (a), wherein the group (b) of pulses includes pulses having a field strength in the range of 1 V / cm to 100 V / cm; and(c) repetition of (a) and (b) in N cycles, N having a value of 0 to 100.

131. A method as claimed in claim 130, wherein the group (b) of pulses include pulses having parameters to induce a stress on the cell membrane, enlarging the cell pores from the group(a) and to facilitate electrophoresis within the tissue, accelerating the loss of ions from the electroporated cells, reducing the capacity for recovery and triggering non-thermal cell death.

132. A method as claimed in claim 131 wherein said (b) group of pulses have parameters to trigger cell death without destruction of an extracellular matrix.

133. A method as claimed in any of claims 130 to 132, wherein the treatment is to achieve haemostasis in said tissue.

134. A method of treatment of bleeding in the GI tract of a mammal, the treatment being carried out with use of a probe having at least two electrodes and a drive circuit controlled by a controller to generate drive pulses, wherein the controller causes the drive circuit to provide pulses in:(a) an electroporation group of pulses sufficient to create / open cell pores and / or disrupt cell membranes of tissue near the electrodes;(b) a secondary group of one or more electrophoretic pulses; and(c) repetition of (a) and (b) in N cycles, N having a value of 0 to 100.

135. A method as claimed in claim 134, wherein the controller sets the value of N and / or the voltage levels for the steps (a) and (b) in order to maintain a tissue temperature below 80 °C, preferably below 70 °C, more preferably below 60 °C.

136. A method as claimed in claim 135, wherein the controller is linked with a temperature sensor for detecting or estimating temperature of tissue being treated and the controller automatically sets the value of N and / or the voltage levels for the steps (a) and (b) in order to maintain a tissue temperature below 80 °C, preferably below 70 °C, more preferably below 60 °C.

137. A method as claimed in any of claims 134 to 136, wherein the group (b) of pulses include pulses having parameters to induce a stress on the cell membrane, enlarging the cell pores from the group (a) and to facilitate electrophoresis within the tissue, accelerating the loss of ions from the electroporated cells, reducing the capacity for recovery and triggering nonthermal cell death.

138. A method as claimed in claim 137, wherein said (b) group of pulses have parameters to trigger cell death without destruction of an extracellular matrix.

139. A method of treating a cardiac condition (e.g., cardiac arrythmia) in a patient as described herein.

140. A method for controlling bleeding in a gastrointestinal tract of a patient, the method comprising: administering a series of high-frequency, short-duration electroporation pulses to a bleeding site within the gastrointestinal tract to open membranes of cells at the bleeding site with a pair of electrodes of an electroporation probe, wherein a frequency of the high-frequency, short-duration electroporation pulses is between 100 kHz and 400 kHz, a duration of each of the high-frequency, short-duration electroporation pulses is between 1 ps and 5 ps, and a voltage of the high-frequency, short- duration electroporation pulses is between 800 V / cm and 2000 V / cm; applying a sequence of lower-voltage, prolonged pulses with the pair of electrodes of the electroporation probe following the administering of the series of high-frequency, short- duration electroporation pulses to induce non-thermal cell death of the cells with the open membranes,wherein a voltage of the lower-voltage, prolonged pulses is between 1 V / cm and 20 V / cm and a duration of each of the pulses is between 0.1 ms and 10 ms; and repeating the pulse sequence for a predetermined number of cycles, wherein the number of cycles is between 5 and 20 cycles, wherein a total duration of the method is less than 1 minute.

141. The method of claim 140, further comprising endoscopically inserting the electroporation probe within a patient and advancing a distal end portion of the electroporation probe to the bleeding site.

142. The method of claim 140 or 141, further comprising repeating the method at multiple different locations.

143. The method of any of claims 140 to 142, wherein the high-frequency, short-duration electroporation pulses comprise biphasic or bipolar pulses of alternating positive and negative polarity.

144. The method of any of claims 140 to 143, wherein the lower-voltage, prolonged pulses comprise monopolar pulses.

145. The method of any of claims 140 to 144, wherein each cycle has a duration of less than one minute.

146. The method of any of claims 140 to 145, further comprising delivering one or more hemostatic agents to the bleeding site.

147. The method of any of claims 140 to 146, wherein the method is performed without delivering any hemostatic agents to the bleeding site.

148. The method of any of claims 140 to 147, wherein the one or more pulses of the secondary group of electrophoretic pulses comprise monopolar pulses.

149. The method of any of claims 140 to 148, wherein each cycle has a duration of less than one minute.

150. The method of any of claims 140 to 149, wherein a total duration of the method is less than one minute.

151. A method of use of an apparatus of any of claims 1 to 74 to perform electrophoretic modulation of epithelial signaling or reprogramming of metabolic signaling pathways.

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