AU2015203303B2 - Apparatus and method for the detection and treatment of atrial fibrillation - Google Patents

Abstract

Embodiments of the invention provide apparatus and methods for the detection and treatment of atrial fibrillation (AF). An embodiment of an apparatus for the detection and treatment of AF comprises an electrical lead having proximal and distal portions. The distal portion is positionable in an atrial chamber with a proximal portion end coupled to a pacemaker. The lead includes a plurality of conductive wires clad with an insulative coating and has sufficient flexibility to be positioned in the atria from a percutaneous or other introductory site. The conductive wires are coupled to a plurality of pairs of bipolar electrodes positioned on a membrane attachable to the heart wall. The electrode pairs are distributed in a pattern defining an area for detecting the location of a foci of aberrant electrical activity and sending a pacing signal to that location to prevent or stop an AF occurrence caused by the foci. WO 2010/123895 PCT/US2010/031748 -"-22, 30 -50,52 A, LA 50, 52 23o RA, A, AC 2 RV, V

Description

ICUB.P011WO 2015203303 17 Jun2015

Apparatus and Method for the Detection and Treatment of Atrial Fibrillation

FI ELD OF THE I NVENTI ON

[001] Embodiments described herein relate to an apparatus and methods for detection and treatment of atrial fibrillation. More specifically, embodiments described herein relate to an apparatus and method for detection and treatment of atrial fibrillation using distributed bipolar electrodes placed on the surface of the heart to detect the earliest onset of fibrillation.

BACKGROUND

[002] The heart has four chambers, the right and left atria and the right and left ventricles. The atria serve as primer pumps to the ventricles which in turn pump blood to the lungs (the right ventricle) or the aorta and the remainder of the body (the left ventricle). The heart is essentially and electromechanical pump, which contracts and pumps blood by means of a wave of depolarization that spreads from the atria to the ventricles in a timed fashion through a series of conduction pathways. Cardiac arrhythmia is a condition afflicting the heart and is characterized by abnormal conduction patterns which in turn can affect the pumping efficiency in one or more chambers of the heart. It can occur in either the atria, ventricles or both. Particular types of Atrial arrhythmia can cause a condition known as atria fibrillation (AF) in which the pumping efficiency of the atria are compromised. Instead of contracting in a coordinated fashion, the left or right atria flutter with little or no pumping efficiency.

[003] During an episode of AF, the normal electrical impulses that are generated by the sino-atrial node (the SA node), the natural pacemaker of the heart are overwhelmed by disorganized electrical impulses, known as ectopic foci that may originate in the atria or pulmonary veins, leading to conduction of irregular impulses to the atria and the ventricles. This can 1 ICUB.P011W0 2015203303 17 Jun2015 result in an irregular heartbeat, known as an arrhythmia which may occur in episodes lasting from minutes to weeks, or years. Left unchecked, AF often progresses to become a chronic condition.

[004] Atrial fibrillation is often asymptomatic, and while not immediately life-threatening, may result in palpitations, fainting, chest pain (angina), or congestive heart failure. Patients with AF have a significantly increased risk of stroke and pulmonary embolism due to the tendency of blood to pool and form clots or emboli in the poorly contracting atria, which are then sent to the lungs in the case of the right atria causing pulmonary embolism, or the brain causing stroke.

[005] Atrial fibrillation may be treated with medications, implanted ventricular defibrillators or surgical procedures. The current medications used either slow the heart rate or revert the heart rhythm back to normal. However, patients must remain on medication for life and many patients cannot be successfully treated with medication. Implanted ventricular defibrillators may be used to deliver a series of high voltage electric shocks to convert AF to a normal heart rhythm in a technique known as synchronized electrical cardioversion. However, these shocks are extremely painful and may cause the patient to pass or literally be knocked to the ground from the shock. Surgical and catheter-based therapies may also be used to ablate or destroy portions of the atria and pulmonary veins containing the ectopic and other foci responsible for the generation of arrhythmias causing AF; however, these require open heart surgery, cardiac catheterization or both and have met with limited success. Thus, there is a need for improved methods and devices for the treatment of atrial fibrillation.

BRI EF DESCRI PTI ON

[006] Embodiments of the invention provide apparatus, systems and methods for the detection and treatment of atrial fibrillation and related conditions. Many embodiments provide a system including a pacemaker 2

ICUB.P011WO 2015203303 17 Jun2015 coupled to endocardial and/or epicardial leads having a distributed pattern of bipolar electrodes for the early detection and treatment of atrial fibrillation.

[007] In a first aspect, the invention provides an endocardial lead having multiple bipolar electrodes that attach to the endocardial surface of the right atria in a distributed pattern for the early detection and treatment of fibrillation in the right atria. Preferably, the electrodes are arranged in a circular or other pattern on the endocardial surface of the right atria to define an area for detecting the location of a foci of aberrant electrical activity causing onset (including earlier onset) of atrial fibrillation. In specific embodiments, the foci can be detected by an algorithm in the pacemaker which identifies the location on the endocardial surface (by the nearest electrode pair) having the earliest activation (i.e., depolarization) during an episode of AF.

[008] Once a foci is detected, the electrodes nearest the foci can then be used to send a pacing signal at that site to prevent the site from causing atrial fibrillation. In some embodiments, that site of early activation can be paced continuously. The lead is coupled to a pacemaker to send sensed signals from each electrode pair back to the pacemaker electronics for analysis to determine the onset of atrial fibrillation or a signal predictive of the onset of atrial fibrillation. The lead can be positioned by in the right atria by introduction and advancement from the jugular vein using cardiac catheterization techniques known in the art.

[009] In particular embodiments, the electrodes can be positioned in a circular, oval or related pattern around the SA node. The electrode pairs can be positioned on a circular or oval shaped patch that is attached to the endocardial surface using a mechanical attachment element such as a helical screw, barbed needle or other attachment means such as a biocompatible adhesive. The adhesive can comprise a thermally activated adhesive that is activated by heat from the body or resistive heating from signals sent to the electrode pair. The patch can comprise a PTFE, polyester 3

ICUB.P011WO 2015203303 17 Jun2015 or other biocompatible material known in the art and is desirably configured to bend and flex with the motion of the heart wall. It may also include one or more nonthrombogenic coatings including coatings impregnated with various elutable drugs known in the art such as TAXOL to prevent thrombus, platelet and other cell adhesion. The electrodes can comprise a radioopaque or echogenic material for visualizing a location of the electrodes in the heart under flouroscopy, ultrasound or other medical imaging modality. Also the patch can include a section made out of such materials to serve as a marker for visualizing the location of the electrodes in the heart.

[010] In a related aspect, the invention provides an epicardial lead having multiple bipolar electrodes that attach to the epicardial surface of the left atria in a distributed pattern for the early detection and treatment of fibrillation in the left atria. Preferably, the electrodes are arranged in a pattern on the epicardial surface of the left atria to electrically map the atria so as detect the location of a foci of aberrant electrical activity causing early onset of atrial fibrillation in the left atria. The pattern includes placement of one or more electrodes adjacent one or more of the pulmonary veins so as to detect foci in these locations. Additionally, in left atria lead embodiments, the lead can also be coupled to a 3-axis accelerometer placed on the epicardial wall of the atria to sense atrial wall motion predictive of atrial fibrillation and normal sinus rhythm. The signal from the accelerometer may be used as a sole indication of AF, or it may be used to supplement the electrical signals from the bipolar leads positioned on the left atria to increase the predictive power of various algorithms used by the pacemaker for the detection of AF. Additionally, sensory inputs from the accelerometer can also be used to assess the effectiveness of atrial pacing signal in preventing AF and/or returning the heart to normal sinus rhythm.

[011] In another aspect, the invention provides an apparatus, system and method for performing low voltage distributed cardioversion for converting the atria from a fibrillative state back to normal sinus rhythm. In these and related embodiments, the pacemaker can simultaneously send a 4 ICUB.P011W0 2015203303 17 Jun2015 higher voltage pacing signal (in the range of 8 to 10 volts) to all pairs of electrodes (e.g., on the particular atrial lead) to stimulate a large enough area of the atria to eliminate the arrhythmia. By using voltages lower than those typically used during external or internal cardioversion (which can be in the hundreds of volts for internal conversion to the thousands for external conversion) the pain experienced by the patient can be greatly reduced.

The other benefit of this approach is that by using bipolar electrodes at each site, the electrical energy delivered to the heart can be contained in a very small region so that the risk of stimulating the ventricles (an unwanted effect in this case) is very small.

[01 2] Further details of these and other embodiments and aspects of the invention are described more fully below, with reference to the attached drawing figures.

BRI EF DESCRI PTI ON OF THE DRAW I NGS

[01 3] Fig. 1 is a lateral view showing an embodiment of a system for the treatment of atrial fibrillation including a pacemaker and various leads going to the atria and ventricles for AF detection and pacing and ventricular pacing.

[014] Fig. 2 is a cross sectional view of the heart showing the placement in the heart of the various leads from the embodiment of Fig. 1 [015] Fig. 3 is a side view of the right atria showing an embodiment of an atrial lead having a distributed pattern of bipolar electrodes placed on the endocardial surface of the right atria for the detection and treatment of AF.

[01 6] Fig. 4 is a side view of the left atria showing an embodiment of a parallel atrial lead configuration connected to a distributed pattern of bipolar electrodes placed on the epicardial surface of the left atria for the detection and treatment of AF.

[017] Fig. 5 is a cross sectional view showing an embodiment of an atrial lead for sensing and pacing. 5 ICUB.P011W0 2015203303 17 Jun2015 [018] Fig. 6a is a top down view showing an embodiment of a bipolar electrode assembly including a pair of bipolar electrodes positioned on a patch or other support layer.

[019] Fig. 6b is a cross sectional view showing positioning of an embodiment of the bipolar electrode assembly on the endocardial wall.

[020] Fig. 7 is a block diagram illustrating some of the typical circuitry on a pacemaker or other implantable pacing or stimulating device.

[021] Figs. 8a-8c are graphs showing an EKG for normal sinus rhythm (Fig. 8a) and during an episode of atrial fibrillation, including the ventricles (Fig. 8b) and atria (Fig. 8c).

DETAI LED DESCRI PTI ON OF THE I NVENTI ON

[022] Embodiments of the invention provide apparatus, systems and methods for the detection and treatment of atrial fibrillation and related conditions. Many embodiments provide a system including a pacemaker coupled to endocardial or epicardial leads having a distributed pattern of bipolar electrode for the early detection and treatment of atrial fibrillation.

[023] Referring now to Figs. 1-2, an embodiment of a system 5 for the detection and treatment of atrial fibrillation comprises a cardiac pace maker or related device 1 0, and one or more leads 20 positionable in/on the atria A and/or ventricles V of the heart H. Leads 20 can be coupled to pacemaker 10 by means of a multi-lead connector 12. In various embodiments, leads 20 can include: a lead 21 positionable on the endocardial wall ENW of the right atria RA for sensing and pacing the right atria; a lead 22 positionable on the epicardial wall EPW of the left atria LA for sensing and pacing the left atria, a lead 23 positionable on the endocardial wall of the right ventricle RV for sensing and pacing the right ventricle and a lead 24 positionable on the endocardial wall of the left ventricle LV for sensing and pacing the left ventricle.

[024] Referring now to Figs. 3-6, in various embodiments, leads 21 and/or 22 can comprise an apparatus 30 for the detection and treatment of 6

ICUB.P011WO 2015203303 17 Jun2015 atrial arrhythmia. Apparatus 30 can comprise a lead 40 having proximal and distal portions 41 and 42 and a plurality of electrode assemblies 50 coupled to the lead. As is described below, electrode assemblies 50 are distributed in a pattern 62 along lead 40 so as to define an area 60 for detecting and locating a foci of aberrant myoelectric activity causing atrial fibrillation. Apparatus 30 including lead(s) 40, can be configured for placement in various locations in the heart including the right atria RA, as is shown in the embodiment of Fig. 3, or the left atria LA, as is shown in the embodiment of Fig. 4. Fig. 4 also shows an embodiment of device 30 having a plurality 40p of leads 40 coupled in parallel to electrode assemblies 50 and pacemaker 10. In these and related embodiments leads 40 can be coupled to a common connector 14, which can be the same as connector 12.

[025] The proximal portion of lead 40 includes an end 41 e configured to be coupled to a pacemaker 10 or a related device. The distal portion 42 of the lead is configured to be positioned in an atrial chamber (right or left) AC of the heart H. Lead 40 comprises an outer sheath 43 surrounding a plurality of conductive wires 44 each having an insulative sheath 45 over all or a portion of their lengths. Conducive wires 44 can comprise copper or other conductive metal known in the art. Desirably, lead 40 also has sufficient flexibility and pushability as is known in the catheter arts to be advanced into the atrial chamber of the heart from a percutaneous introductory site such as the jugular vein in the neck or other like site.

[026] In many embodiments, electrode assembly 50 comprises a pair 51 of bipolar electrodes 52 which are disposed in or otherwise positioned on a patch 53 or other support layer or structure 53 that can be attached to the heart wall. Electrode assembly 50 and electrodes 52 are configured to sense electrical activity within a region of myocardial tissue MT within the heart wall HW of the atria to detect an ectopic or other foci F of abnormal electric activity and send a pacing signal 56 to the heart wall to depolarize region MT containing the Foci F. Electrodes 52 are typically circular and can have diameters in the range of 1 to 10 mm with specific embodiment of 2, 5 7

ICUB.P011WO 2015203303 17 Jun2015 and 7 mm, larger sizes are also contemplated. They can comprise various conductive metals known in the art including gold, platinum, silver, stainless steel and alloys thereof. They are desirably positioned on the tissue contacting surface 55 of assembly 50, but also may be recessed within the interior of the assembly so as to be capacitively coupled to the heart wall.

[027] In preferred embodiments, the electrodes 52 of electrode assembly 50 are configured as bipolar electrodes. Such embodiments allow the depth of electrical energy delivered to myocardial tissue for purposes of pacing and cardioversion to be precisely controlled. However in alternative embodiments, electrodes 52 can be configured as monopolar electrodes with current flowing to a return electrode (not shown) positioned at another location on lead 40 or another lead 20.

[028] Electrode assembly 50 can be attached to the heart wall HW through several different means. According to an embodiment shown in Fig. 6b, the patch can include one or more attachment elements 57 that have tissue penetrating anchoring portions 57a which penetrate and anchor into the heart wall HW. Suitable attachment elements 57 can include various helical coils or barbed needles as is shown in Fig. 6b. Patch 53 may also be attached to the heart wall through use of biocompatible adhesives known in the art. In specific embodiments, the adhesive can comprise thermally activated adhesives that are activated by heat from flowing blood or electrical energy delivered from electrodes 52.

[029] In various embodiments, lead 40 can include a plurality of electrode pairs 52/assemblies 50 which can be positioned in a distributed arrangement on the lead. In particular embodiments, the lead 40 can include between 2 to 10 pairs of electrodes with specific embodiments of 3, 4, 5, 6, 7 and 8 electrode pairs. Greater and lesser numbers of electrode pairs also contemplated depending upon the size and shape of atrial or ventricular chamber. The electrode pairs can be substantially equidistant from each with other spacing arrangements also contemplated. For example, particular spacing arrangements can be configured to account for 8

ICUB.P011WO 2015203303 17 Jun2015 the shape and size of a particular patient’s atria which can be determined by prior imaging of the patient’s heart. In specific embodiments, the spacing between electrode pairs 52 can be in the range from about 1 to about 5 cms with greater and lesser distances also contemplated.

[030] Desirably, the spacing and number of electrodes pairs 52 on lead 40 or other lead are configured to allow the electrodes to sense the electrical activity (e.g., the amount and time course of depolarization) of a selected area 60 of myocardial tissue MT within the atria or ventricle. This in turn, allows for the generation of a conduction map 61 of tissue area 60. Conduction map 60 can be used to detect for the presence of one or more ectopic or other foci F of aberrant electrical activity within area 60.

[031] In various embodiments, electrode pairs 52 can be arranged in a circular, oval or other distributed pattern 62 around a selected area 60 of the atrial or ventricular wall as is shown in the embodiments of Figs. 3 and 4. In particular embodiments, electrode pairs 52/assemblies 50 are arranged in circular, oval or other pattern 62 around the SA node as is shown in the embodiment of Fig. 3 (desirably, the electrode pairs 52 are positioned to be substantially equidistant from the SA node). Such embodiments allow for the detection of particular foci F causing premature depolarization of the Atria by allowing comparison of the earliest depolarization within the entire area 60 (or adjacent to it) to that of the SA node. As is described herein, software algorithms resident 130 within pacemaker 10 can be used to detect the location LF of such foci F and then send a pacing signal to that location to take conductive control of the Foci and prevent it from causing AF.

[032] In addition to electrodes 52, lead 40 can also include other sensors 70 for detection of various electrical and/or mechanical properties.

In particular embodiments, sensors 70 can include an accelerometer 70, such as a 3 axis accelerometer for detection of atrial or other heart wall motion as is shown in the embodiment of Fig. 4. Similar to electrodes 52, sensors 70 can be arranged in selectable distributed pattern 62 on the 9

ICUB.P011WO 2015203303 17 Jun2015 endocardial or epicardial surface of the heart, such as a circular, oval or other pattern.

[033] Patch 53 will typically have an oval or other like shape, particularly for bipolar electrode embodiments, though other shapes are also contemplated. All or a portion of the patch can comprise various biocompatible polymers known in the art including PTFE, polyurethane, silicone and various other elastomers known in the art. Desirably, patch 53 has sufficient flexibility to conform to shape of heart wall as well as bend and flex with the motion of the heart so as to remain attached to the heart wall and not impede the motion of the heart wall. Patch 53 can also include one or more biocompatible non-thrombogenic coatings 58 such as silicone or other elastomeric coating. Coatings 58 can also have one or more drugs 58d embedded in the coating, so as to be elutable over an extended period of time up to years. Drugs 58d can include various compounds such as Taxol or compounds known in the stent arts for reducing platelet and cellular adhesion to the patch. Drugs 58d can also include various antibiotics and antimicrobials such as vancomyacin, cefamandol, gentamicin and silver compounds for reducing the likelihood of bacterial adhesion and growth, or infection of patch 53. In some embodiments, patch 53 can have a multilayer construction, in these and related embodiments, coating 58 can comprise a layer 58 which will typically be a tissue contacting layer 58.

[034] In various embodiments, all or a portion of patch 53 and/or electrodes 52 can comprise a radio-opaque or echogenic material for visualizing a location of assembly 50 and/or electrodes 52 in the heart under flouroscopy, ultrasound or other medical imaging modality. Suitable radioopaque materials include platinum and titanium dioxide. In particular embodiments, patch 53 can include a marker section 59 made out of such materials for visualizing the location of the electrode pair 51. Desirably, marker 59 is centrally located on the patch so as to be equidistant from each electrode 52, to enable the physician to use the marker as a guide for 10

ICUB.P011WO 2015203303 17 Jun2015 placing the electrodes at a desired location on the heart wall. Alternatively, marker 59 can be positioned on an edge of patch 53 as is shown in Fig. 6a.

[035] In use, markers 59 allow for the precise placement of the electrode assemblies 50 along the endocardial wall of either the atria or the ventricles so as to define the selectable area 60 of the heart for measurement of electrical activity. For example, in particular embodiments the markers can be aligned with a superimposed image of an alignment template that marks the desired location for each electrode assembly. The markers also allow the physician to determine, through various cardiovascular imaging methods, that the electrode assemblies remain attached to heart wall over time. Additionally, once an ectopic or other foci F of aberrant electrical activity has been detected, they can be used as a point of reference for performing various RF ablative procedures to ablate the area of tissue responsible for the foci or otherwise create a conduction block around it.

[036] Referring now to Fig. 7, pacemaker 10 can include various circuitry and other components. Some of the typical circuitry 110 and electronic devices 120 in a pacemaker 10 or like device can include power control circuitry 111, amplification and sensing circuitry 11 2, pacing circuitry 113, telemetry circuitry 114, micro-controller/micro-processor devices 121 and memory devices 122. One or more software algorithms 130 can be stored in memory device 122 and/or processor 121 for implementation by processor 121. Such algorithms 1 30 can include cardiac mapping and foci detection algorithms, pacing algorithms (both atrial and ventricular), atrial fibrillation detection algorithms, ventricular fibrillation detection algorithms, cardioversion algorithms (high and low voltage (e.g., 8 to 10 volts)) and combinations thereof.

[037] In embodiments of methods for positioning apparatus 30 in the body, the physician can place the endocardial lead in the right atrium by advancement from a percutaneous introductory site in the jugular vein or a related site. As described above, the desired positioning of the electrode assemblies 50 in the atria can be achieved by imaging the heart during 11

ICUB.P011WO 2015203303 17 Jun2015 placement and observing the position of markers 59. The epicardial leads can be placed using surgical techniques such as a mini-thorocotomy or a minimally invasive procedure using endoscopy. Additional leads can be positioned as needed in the right or left ventricles using minimally invasive or surgical techniques. One or more of these leads can be subsequently coupled to a pacemaker 10 positioned in the chest or other location.

[038] In exemplary embodiments of methods for using the invention, system 5 and atrially positioned leads 40 can be used to detect and treat atrial fibrillation in the following fashion. The distributed electrode assemblies can be used to monitor the patient’s EKG including the P wave as well as map conduction in the area within or adjacent that circumscribed by the electrode assemblies, preferably this area includes the SA node. Atrial fibrillation can be detected based on the elimination or abnormality of the P wave as is shown in Figs. 8b and 8c. When AF occurs, using the conduction map, the location of the ectopic or other foci causing the atrial fibrillation can be identified by looking at the time course of depolarization and identifying locations that depolarize before the SA node. Cardioversion can then be performed as described below to return the heart to normal sinus rhythm.

[039] After cardioversion is performed and the heart returned to normal sinus rhythm, the electrode assemblies nearest that foci can then be used to send a pacing signal to that site and surrounding tissue to prevent the site from causing another episode of atrial fibrillation. Also, the location of that site can be stored in memory of the pacemaker so that next time abnormal atrial depolarization is detected, a pacing signal can be sent immediately to that site to prevent the occurrence of AF. In some embodiments, a site of early activation can be paced continuously. Atrial pacing can be performed to produce a stimulated Pwave, Ps which can be triggered off the R wave, R, or the R to R interval, R, as is shown in Figs. 8a and 8b with appropriate time adjustment Ta for firing during the time period Tp when the normal P wave would be expected to occur. 12 ICUB.P011W0 2015203303 17 Jun2015 [040] In addition to detection of foci and other early activation/abnormal conductions sites in the atria, atrial fibrillation can also be detected using an accelerometer 71 such as a 3-axes accelerometer placed on the atrial wall (either epdicardial or endocardial) to sense atrial wall motion as is shown in the embodiment of Fig. 4. Such motion is predictive of atrial fibrillation via the effects atrial fibrillation has on atrial wall motion which typically flutter as a result. The signal from the accelerometer can be used to supplement the electrical signals from the bipolar leads positioned on the left atria to increase the predictive power of various algorithms used by the pacemaker for the detection of AF. Additionally, sensory inputs from the accelerometer can also be used to assess the effectiveness of an atrial pacing signal in preventing AF and/or returning the heart to normal sinus rhythm.

[041] As described above, when an episode of atrial fibrillation has been detected embodiments of the invention can also be used for performing cardioversion to convert the atria from a fibrillative state back to normal sinus rhythm. In these and related embodiments, the pacemaker can simultaneously send a higher voltage pacing signal (in the range of 8 to 10 volts) to all or a majority of the pairs of distributed electrodes to simultaneously depolarize (also described herein as conductively capture) a large enough area of the atrial myocardium to stop the aberrant currents causing the atrial fibrillation. These voltages, while higher than those used for pacing to prevent AF, are much lower than those typically used during conventional internal cardio version (in the hundreds of volts) or external cardioverions (in the thousands of volts). Such lower voltages can be used because the stimulation is delivered by a multipoint source (resulting in higher current densities) and to a much smaller area of the heart than during typical internal or external cardioversion. By using voltages lower than those typically used during internal or external cardioversion, the pain experienced by the patient can be greatly reduced. The other benefit of this approach is that by using bipolar electrodes at each site, the electrical energy delivered to the heart can be contained to a relatively small region so that the risk of stimulating the ventricles (an unwanted effect in this 13 ICUB.P011W0 2015203303 17 Jun2015 case) is very small. The voltage level for achieving cardioversion can be adjusted based on one or more of the following factors (the “conversion voltage adjustment factors”): i) the size of the area of tissue bounded by distributed electrode pairs (smaller areas require less voltage); ii) the location of the ectopic foci (the closer the foci to a particular electrode pair the less the required voltage); iii) the number of foci (larger number of foci may require larger voltages); iv) the number of electrode pairs defining the area (the more electrodes the lower the voltage); and v) the number of prior episodes of AF (a larger number of episodes may require higher voltage). One or more of these factors can be programmed into the algorithm resident within the pacemaker which controls the cardioverion process. Also the conversion algorithm can programmed to use the lowest possible voltage at first, and then progressively increase it until conversion is achieved. The voltage which achieves conversion can then be stored in memory and used again as a starting point in a subsequent conversion attempt with tuning or fine tuning using one or more of the five conversion voltage adjustment factors described above.

CONCLUSION

[042] The foregoing description of various embodiments of the invention has been presented for purposes of illustration and description. It is not intended to limit the invention to the precise forms disclosed. Many modifications, variations and refinements will be apparent to practitioners skilled in the art. For example, embodiments of the apparatus for detection and treatment of atrial arrhythmias and fibrillation can also be adapted for detection and treatment of various ventricular arrhythmias.

[043] Elements, characteristics, or acts from one embodiment can be readily recombined or substituted with one or more elements, characteristics or acts from other embodiments to form numerous additional embodiments within the scope of the invention. Moreover, elements that are shown or described as being combined with other elements, can, in various embodiments, exist as standalone elements. Flence, the scope of 14 ICUB.P011W0 2015203303 17 Jun2015 the present invention is not limited to the specifics of the described embodiments, but is instead limited solely by the appended claims.

[0044] Throughout this specification and the claims which follow, unless the context requires otherwise, the word "comprise", and variations such as "comprises" and "comprising", will be understood to imply the inclusion of a stated integer or step or group of integers or steps but not the exclusion of any other integer or step or group of integers or steps.

[0045] The reference to any prior art in this specification is not, and should not be taken as, an acknowledgement or any form of suggestion that the prior art forms part of the common general knowledge in Australia. 15

Claims (29)

1. WHAT IS CLAIMED IS:

   1. An apparatus for detection and treatment of atrial arrhythmia, the apparatus comprising: an electrical lead having a proximal and distal portion, the distal portion being positionable in an atrial chamber of a heart, the proximal portion having an end configured to be coupled to a pacemaker device, the lead having sufficient flexibility to be advanceable in the atrial chamber of the heart from a percutaneous introductory site; a plurality of membrane patches distributed along the electrical lead, each membrane patch configured to be attached to a wall of the heart and to bend and flex with motion of the heart without impeding motion of the heart; and a plurality of pairs of bipolar electrodes, wherein at least one pair of electrodes is positioned on each membrane patch, the electrodes of each pair being (i) electrically coupled to the lead, and (ii) configured to at least sense an electrical signal of the wall of the heart; wherein the distribution of the plurality of membrane patches and electrode pairs along the lead is configured to allow the plurality of electrode pairs to be distributed in a pattern on the wall, the pattern defining an area for i) detecting a location of a foci of aberrant electrical activity located within or adjacent the area, and ii) sending a pacing signal to that location to prevent or stop an occurrence of atrial fibrillation caused by that foci.
2. 2. The apparatus of claim 1, wherein at least one of the electrode pairs includes a marker for visualizing a location of the electrode pair in the heart using a medical imaging modality.
3. 3. The apparatus of claim 2, wherein the marker is a radio-opaque or an echogenic marker.
4. 4. The apparatus of claim 1, wherein the plurality of electrode pairs are configured and arranged in a pattern defining an area to send a simultaneous signal to the area to depolarize substantially the entire area so as to convert a fibrillative state of the atria to normal sinus rhythm.
5. 5. The apparatus of claim 1, wherein the plurality of electrode pairs are arranged in a substantially circular pattern.
6. 6. The apparatus of claim 1, wherein the plurality of electrode pairs are arranged in a pattern defining an area containing the sinoatrial (SA) node.
7. 7. The apparatus of claim 1, wherein the membrane comprises PTFE, silicone, polyurethane and/or polyester.
8. 8. The apparatus of claim 1, wherein the membrane comprises an attachment element for attaching the membrane to the wall of the heart.
9. 9. The apparatus of claim 1, wherein the membrane includes a non-thromobogenic coating.
10. 10. The apparatus of claim 9, wherein the coating includes an elutable drug for reducing cellular adhesion to the membrane.
11. 11. The apparatus of claim 1, wherein the atrial chamber is the right atrial chamber.
12. 12. An apparatus for the detection and treatment of atrial arrhythmia, the apparatus comprising: an electrical lead having a proximal and distal portion, the distal portion configured to be positioned on an atrial chamber of a heart, the proximal portion having an end configured to be coupled to a pacemaker device, the lead having sufficient flexibility to be advanced to the atrial chamber of the heart from an introductory site; a plurality of membrane patches distributed along the electrical lead, each membrane patch configured to be attached to a wall of the heart and to bend and flex with motion of the heart without impeding motion of the heart; and a plurality of pairs of bipolar electrodes, wherein at least one pair of electrodes is positioned on each membrane patch, the electrodes of each pair being electrically coupled the lead, wherein the distribution of the plurality of membrane patches and electrode pairs along the lead is configured to allow the plurality of electrode pairs to be distributed in a pattern on the heart wall, the pattern defining an area for detecting a location of a foci of aberrant electrical activity located within or adjacent to the area and sending a pacing signal to that location to prevent or stop an occurrence of atrial fibrillation caused by that foci.
13. 13. A system for the detection and treatment of atrial arrhythmia, the system comprising: an implantable pacemaker; and the apparatus of claim 12, wherein the lead is electrically coupled to the pacemaker.
14. 14. A method for treating and/or preventing atrial fibrillation in a patient, the method comprising: providing an apparatus comprising: an electrical lead having a proximal and distal portion, the distal portion configured to be positioned on an atrial chamber of the heart; the proximal portion having an end configured to be coupled to a pacemaker device; and a plurality of pairs of bipolar electrodes, the electrode of each pair being (i) electrically coupled to the lead, (ii) positioned on a membrane patch configured to be attached to a wall of the heart, and (iii) configured to at least sense an electrical signal of the wall of the heart; placing a plurality of membrane patches on the wall of the heart to position the plurality of pairs of bipolar electrodes in a pattern to define a detection area for detecting aberrant electrical activity in the heart; measuring electrical activity of the heart using at least a portion of the plurality of bipolar electrodes; and detecting a foci of aberrant electrical activity in the heart causing the onset of atrial fibrillation (AF) using the measured electrical activity.
15. 15. The method of claim 14, wherein the plurality of membrane patches are positioned on an endocardial surface of the heart.
16. 16. The method of claim 14, wherein the plurality of pairs of bipolar electrodes are arranged in a substantially circular or oval pattern.
17. 17. The method of claim 14, wherein the foci is detected by identifying a location in the detection area which depolarizes before the patient’s SA node during an episode of AF.
18. 18. The method of claim 14, wherein the foci is detected by identifying a location in the detection area which has the earliest depolarization during an episode of AF.
19. 19. The method of claim 14, wherein the foci is detected by detecting an abnormal Pwave in the patient’s EKG.
20. 20. The method of claim 14, further comprising sending a pacing signal to the foci to prevent the foci from causing AF.
21. 21. The method of claim 20, wherein the pacing signal is sent continuously.
22. 22. The method of claim 20, wherein the pacing signal is sent using a pair of electrodes of the plurality that is nearest the detected foci.
23. 23. The method of claim 20, wherein the pacing signal is configured to produce a stimulated Pwave.
24. 24. The method of claim 20, wherein the pacing signal is triggered off of the patient’s R-wave or R to R interval.
25. 25. The method of claim 14, wherein the foci is detected by the absence or abnormality of a measured signal representative of the patient’s P-wave.
26. 26. The method of claim 14, further comprising: sensing a wall motion characteristic of the atria using an accelerometer placed on the wall of the atria; and using the sensed wall motion characteristic to detect the occurrence or absence of AF.
27. 27. The method of claim 26, wherein the accelerometer is placed on the epicardial wall of the atria.
28. 28. The method of claim 26, wherein AF is detected using analysis of both the sensed wall motion and the measured electrical activity.
29. 29. The method of claim 26, further comprising: sending a pacing signal to the foci to prevent the foci from causing AF, wherein the sensed wall motion characteristic is used to assess the effectiveness of the pacing signal in preventing AF and/or returning the heart to normal sinus rhythm.