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 . referring now to fig1 - 2 , an embodiment of a system 5 for the detection and treatment of atrial fibrillation comprises a cardiac pace maker or related device 10 , 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 mufti - 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 . referring now to fig3 - 6 , in various embodiments , leads 21 and / or 22 can comprise an apparatus 30 for the detection and treatment of 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 63 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 fig3 , or the left atria la , as is shown in the embodiment of fig4 . fig4 also shows an embodiment of device 30 having a plurality 40 p 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 . 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 . 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 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 . 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 . electrode assembly 50 can be attached to the heart wall hw through several different means . according to an embodiment shown in fig6 b , the patch can include one or more attachment elements 57 that have tissue penetrating anchoring portions 57 a 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 fig6 b . 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 . 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 the shape and size of a particular patient &# 39 ; s atria which can be determined by prior imaging of the patient &# 39 ; 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 . 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 . 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 fig3 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 fig3 ( 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 . 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 fig4 . similar to electrodes 52 , sensors 70 be arranged in selectable distributed pattern 62 on the endocardial or epicardial surface of the heart , such as a circular , oval or other pattern . 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 . 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 more drugs 58 d embedded in the coating , so as to be elutable over an extended period of time up to years . drugs 58 d can include various compounds such as taxol or compound known in the stent arts for reducing platelet and cellular adhesion to the patch . drugs 58 d 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 . 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 radio - opaque 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 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 fig6 a . 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 . referring now to fig7 , 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 112 , 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 130 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 . 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 placement and observing the position of markers 59 . the epicardial leads can be placed using surgical techniques such as a mini - thoracotomy 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 . 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 &# 39 ; 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 fig8 b and 8 c . 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 . 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 p wave , p s which can be triggered off the r wave , r , or the r to r interval , r i as is shown in fig8 a and 8 b with appropriate time adjustment ta for firing during the time period tp when the normal p wave would be expected to occur . 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 fig4 . 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 atrial pacing signal in preventing af and / or returning the heart to normal sinus rhythm . 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 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 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 . 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 . 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 . hence , the scope of the present invention is not limited to the specifics of the described embodiments , but is instead limited solely by the appended claims .
embodiments of the invention provide methods for the detection and treatment of atrial fibrillation and related conditions . one embodiment provides a method comprising measuring electrical activity of the heart using electrodes arranged on the heart surface to define an area for detecting aberrant electrical activity and then using the measured electrical activity to detect foci of aea causing af . a pacing signal may then be sent to the foci to prevent af onset . atrial wall motion characteristics may be sensed using an accelerometer placed on the heart and used with mea to detect af . the wmc may be used to monitor effectiveness of the pacing signal in preventing af and / or returning the heart to normal sinus rhythm . also , upon af detection , a cardioversion signal may be sent to the atria using the electrodes to depolorize an atrial area causing af and return the heart to nsr .