for this session. So we're excited that you guys have joined us. But we are gonna dive right in because we've got a lot of content to cover in the hour that we have. There will be time at the end for Q&A. So you can use your app to submit those questions or there'll be a QR code on the screen. But without further ado, I am going to first introduce, I believe we're starting with Dr. Silverstein. Thank you. Thank you, Janice, and thank you, Tara, for moderating this session. Let me start this. It's the awkwardly long disclosure slide. Yeah. Yeah. It takes three seconds. So I was asked to speak about how do we advance quality of care delivery and the role of a center of excellence, and I was supposed to give the perspective coming from a private practice EP, which is not a private practice EP, but I have done just a little bit about myself. So I practiced in private practice for one year coming out of fellowship, and then I've been in a hospital-employed non-academic model, and now I'm in a hospital-employed academic model. So I've kind of covered all the bases. I'm at Allegheny Health Network in Pittsburgh, Pennsylvania, and I was really excited this week when we got news that this publication was gonna be published on Wednesday online, and this was a document we'd been working on for about a year and a half, and I was just speaking with Jared Bunch before the session, and it's about criteria for the establishment of an atrial fibrillation center of excellence, key operational standards, and we all felt that this was something that was lacking, that we had talked, there was a lot of talk about AFib centers of excellence. There was a large document going over all the different aspects of an AFib center of excellence, but it was still rather unclear about what it is that you need to do to be an AFib center of excellence, or what your institution should look like. So that's the purpose of this document. If you haven't read it, I encourage you all to do so. It's not 50 pages. It's much shorter, and a lot of very good figures and checklists and hopefully information that can help all of us deliver better patient care. So why did we go about writing this? The goal is to establish a standard for what defines a center of excellence, as I just mentioned. It's meant to empower the medical community to become centers of excellence and improve patient care. Also to have a framework to construct a center of excellence, and to work with a multidisciplinary team to achieve best possible patient care. It should be inclusive of all practices, whether you're rural, suburban, inner city, all different sizes, all different settings, and all different healthcare systems. The goal is actually, we want everyone to be an AF center of excellence. We don't want this to be a club that only a few institutions can join. But ideally, every place tries to become an AF center of excellence, and now result in better patient care for everybody with facial fibrillation. So center of excellence, I'm sure you've seen signs around that say, this is a neurologic center of excellence, a stroke center of excellence. So a center of excellence is a specialized program within a healthcare setting that provides exceptional care in a specific area. The characteristics that define a center of excellence, it should be multidisciplinary collaboration. It's not just EP. And actually EP, I would argue, we can be involved in leadership, but we shouldn't be the main part of this. We're a spoke in the wheel. And maybe, hopefully involved in leadership, but we are not the center of excellence. It's a multidisciplinary collaboration. There should be standardized protocols that it shouldn't be that if you go see me, and you go see one of my partners, you get totally different care. You should get very similar care that's based on protocols and best practices. There should be continuous quality improvement that every place that starts this journey is gonna be at a different spot. The idea is to keep moving upwards and to make incremental improvements. That's what quality improvement is. And so if that's what's accomplished with this AF center of excellence document, that would be excellent. That everybody's trying to do better. That's really the point. And of course, the patient should be at the center of everything we do. So I was asked to give my three pearls. So here's pearl one. The patient should be the center. This is a figure from the document. The, we should have shared decision making tools. They're shared across different institutions. By the way, I'm gonna put a plug. I was debating whether to do this or not, but cardiq.org is a great resource. You're gonna find a lot of the tools you need to become a center of excellence. And actually, if you don't see the tools on there, there's actually, there's a discussion page now that you've seen in other HRS forums. Ask a question to the community. There are a lot of us that are following in the community. They're happy to share with you what we've already done. And so if you don't see anything in our resource library on CardiQ, then put a question to the community. And I bet there's somebody in the community that could help you out, so you don't have to start from scratch. So the idea is to take all these materials, all these pathways, protocols, to enhance patient satisfaction and adherence to treatment plans. Pearl number two is leverage data for continuous improvement. I always say that in order to do quality improvement, you have to do data collection. It empowers you. First of all, you have to know where you're starting. How are you gonna know if you improve if you don't know where you started? And so start by measuring something. And for us, one of my passions is lab efficiency and getting turnover in lab, which is a huge quality improvement initiative. Measure stuff. Figure out where you're starting. How long does it take your doctors to get to the room? How long does it take you to get access? How long does it take to turn over a lab? And work on it. Pick a few goals. Don't try doing everything all at once. And then celebrate your successes. When you see the numbers coming down and that you're meeting your metrics, you know, you're anticoagulating more patients than you were before, that you're getting patients in quicker than they used to, celebrate those successes. Pearl number three is foster the multidisciplinary collaboration. This cannot be done with just EP. It should not be EP-centric. It should be patient-centric. And we are a part of that, an integral part of that plan, but it's gotta involve all the different disciplines that are in this figure. And all these figures, by the way, are from the document. So specific considerations. I was asked to give the private practice EP perspective. A few things that come to mind from the document is that private practice physicians, they should have access to the same care pathways and resources as employed physicians. We thought that was really important. And having been in private practice, I wouldn't like it if the employed guys had resources and stuff I didn't. So that's really important that if there is an AF Center of Excellence, if they're gonna call themselves an AF Center of Excellence, it's gotta be open to both employed and private physicians. The other is that private practice physicians should be invited to participate in the leadership and developing protocols, pathways, and helping advance patient care. This is also very important, and it's different. This is more with the patient at the center, that if you're a patient and you're going to a center that's a center of excellence, you should know that all the physicians are being held to the same standards whether they're employed or not. And so I think that this is really important that if there's a private practice physician going to a center of excellence and they have lab quality improvement initiatives, they need to participate. And if they're not, then you're not a center of excellence until that occurs. So in conclusion, the centers of excellence can significantly improve care for patients with atrial fibrillation. That is the whole purpose of all this that we're talking about today. It should be focused on the patient. We need to collect data, use the data, celebrate successes, and we have to collaborate with others. And my call to action to all of you is take this information back to your facilities and figure out what it means for your facility to become a center of excellence and do it. And thank you. Next I'd like to invite to the stage Dr. Jennifer Wright who will speak to us about the three pearls of wisdom from an academic perspective. All right, hi everybody. I'm happy to be here. I'm Jen Wright from the University of Wisconsin. You're gonna hear a lot of overlap today in recurring themes when it comes to our pearls of wisdom. So I'll give you mine as well. And I'm glad that Josh told me that this was a five minute talk rather than a 10 minute talk because I'd be up here talking forever about this. So all right, so objectives, here are my three pearls. First, you gotta build your team. Second, use your resources and avoid redundancy. And third, understand that this is going to be a process. So talking about building your team, who do you select? This is actually the most important first step of developing your AFCOE. So before you get to the details of the how, you have to find your people that can make the dream work. So Danny Ocean had it right. Before he actually robbed the Bellagio, he got the team members who knew their certain characteristics to bring it to the table. So similar to building an AFCOE, this is what we have to do. So for your team members that you wanna look for, you gotta get those people who can assist with organizational buy-in. So who knows who who can get the job done. Also those people who have prior experience in QI work. And also share your passion. Get your why and have their why as well. And also you gotta have team members representing various roles throughout the community and throughout your center. And so this diagram from the original framework of the AFCOE, I think does it well. Because we're very EP-centric sometimes when we're thinking about an AFCOE. And as Josh said, that's not really the case. We need to have everybody involved and everybody who touches an AF patient. So looking even within your EP team, you have to involve lab leadership, have to involve anesthesia, your MDs, your APPs, your techs, your RNs, and your fellows. And so this is, when you are a teaching center, fellows actually can be advantageous for developing an AFCOE. Because your learners are the ones who are gonna pay it forward. Because this process doesn't stop with us. This process is a shared process and they need to then take it to where they're going to practice. And it also provides them with the tools that they need to know what quality care is. So teamwork does make the dream work as it did for the Red Sox. Sorry, Josh. Okay. So the next pearl is use your resources. So this picture says it well. Let's not reinvent the wheel. And so when you develop an AFCOE, when you look at, we already have the framework and as you're gonna hear multiple times today, now as of three days ago, we have the criteria. So where can you start to see where you're at now and where you need to go? And so this areas of opportunity graphic gives you at least some guide as to what categories to start in. So for example, standardizing the pathways, the workflows, finding what everybody agrees on and what works for the majority of patients. So we did this at UW. Once, twice, three, four, five, six, more than that. So starting from the beginning takes a lot of time and it is redundant. So here's the other plug for CardiQ. We don't need to create redundancy. We don't need to reinvent the wheel. We don't need to work in silos. So we can use this as a resource library. If you wanna make a business plan, if you wanna make a workflow, you can go to CardiQ and type it in and pull up your resource library and you can also share. If you think you have a great business plan or a great workflow, please add it to CardiQ. So another area of opportunity with developing AFCOE is educational resources for both providers and for patients. And so we not only have CardiQ, but we also have Upbeat where you can refer your patients to go to where if they wanna learn about AFib, they can get their questions answered. So another key component to the AFCOE and using your resources when we're talking about early access. So Josh was talking about EP lab efficiency. Yes, that's one of the parts of getting early access for our patients. And there are opportunities to learn where to start. For example, in the HRS 365, EP lab efficiencies. But also how about talking to people who have done the work? And you'll see some people, this is who we met with when we were starting our work at UW. So we met with Dr. Zivgrosky, Dr. Osario, and Dr. Silverstein to see what they did so we could learn from them. Similar to developing an AFib clinic. That's another way to garner early access for your AFCOE. So meet with those who have done the work. And we have one of the panelists here, Andrea Robinson, in addition to Anisha Meen, James Allright, and many, many other folks who are not on the slides here today. Third pearl, understand that this is a process. You have to start somewhere. So start with what you think you're gonna be able to accomplish. Because when you do get those wins, celebrate those wins and know that that takes and garners momentum going forward for those tougher, higher-reaching projects. And start with your EP team. See what you can all agree on. And understand that everybody has to give up a little bit, be a little bit flexible, and understand also that change is hard. I mean, this is gonna be said over and over again today. Know your data. You have to, because you have to know what you have to work on. You have to know and continually review your data. And have regular meetings with your core team members, but also with those who are sending patients to you and your patients, because you wanna get that feedback from them. Feedback is a good thing. We learn, we get better from feedback. So prepare for turbulence. Get your seatbelt on, because setbacks and hurdles will occur. So kind of like Carol Danvers, before she came, Captain Marvel, she was down, and then she would get up. So that's sometimes what you have to do in this process, because there will be days where it's not smooth. So also, so try not to get discouraged, and also understand your worth and the ability to advocate. So if you haven't checked out this document, please do. I think it'll be super helpful for you. Thank you all. Thank you. Next up is Lauren Rousseau, who will be speaking with us about three additional pearls of wisdom. Okay, good morning, everyone. My name is Lauren Rousseau. I'm a PA at Brigham and Women's Hospital, and I'm going to be providing the allied professional perspective. So my three pearls of wisdom. Where do we start? Well, I wanted to start with our AP's role in a versatile care model. Our AP's participate in the outpatient, inpatient, and procedural model, which we believe helps improve patient experience, streamlines care delivery with fewer groups involved. From the AP standpoint, we feel as though this is a more optimal approach compared to being in a silo. We are a wonderful liaison between physicians, patients, patient family members, device representatives, and other care teams and care departments. We are effective at closing loops in a timely reporting manner, flagging red alerts, aligning plans of care. We participate in regular huddles, care conferences, and shared EHRs, which help maintain continuity and clarity. And so I wanted to share a brief case study which shows the allied professional involvement in AFib management care continuum. So this is a 60-year-old female. She has a history of hypertension, hyperlipidemia, heart failure with a reduced EF, for which she has a dual chamber ICD in situ. She had a recent diagnosis of AFib and was started on anticoagulation. She's followed in the device clinic by the allied professional who she sees annually. The patient presented to the emergency department with AFib with RVR. She had signs of acute decompensated heart failure. So she was admitted to the cardiology team. She was started on rate control and underwent IV diuresis. Prior to discharge, the cardiology team reached out to the allied professional cardioversion pager, at which time we performed a cardioversion and she was discharged later in that hospital stay. Two months later, she presented for an elective atrial fibrillation ablation. Her procedure was uncomplicated. However, she was suffering from acute decompensated heart failure. She was admitted to the allied professional EP team and underwent further IV diuresis and then discharged two days after the procedure. She did well post-procedurally. However, she called the clinic and said that AFib recurred. And so at that time, we placed her in a virtual clinic with our allied professional, at which time we discussed antiarrhythmic initiation and planned another outpatient cardioversion. At the time of her four-month post-ablation follow-up, she again met with the allied professional, at which time she was in sinus rhythm. Antiarrhythmics were discontinued and the patient was happy and everyone was happy. So this is a perfect model of the allied professional involvement in AFib patients in our care continuum. My second pearl is utilizing the virtual care components to improve patient and provider experience. Now, we all know in the setting of the COVID pandemic that our virtual care truly expanded and changed the way that we manage patients. And so utilizing that to, again, improve provider and patient care is so important. We also know that in medicine, it's our expectation that we continue to evolve and to expand our knowledge base, and especially within EP, with ever-evolving technology, devices, remote monitoring, utilization of AI, et cetera. And we feel as those centers of excellence invest in education and innovation, and allied professionals are truly able to rise to that challenge. And ultimately, we feel that quality care means adaptive care. And lastly, the importance of patient education and resource allocation. So really understanding the importance of being a consistent presence for our patients, from diagnosis to post-procedure follow-up to, again, long-term care management of these chronic conditions. My colleague, Julie Hsieh, hosts an annual AFib symposium, which is a virtual group that you can attend, and we have didactic sessions, which talks about AFib diagnoses, different treatment managements in terms of antiarrhythmics, ablation, risk factor modification, et cetera. It also offers an opportunity for patients to engage and ask questions. In addition, we host quarterly ICD support group meetings, which allows patients living with ICDs or patients who are considering ICDs, again, to share stories, to participate in some didactic and education sessions, to learn from each other. So we feel that patient education empowers patients with knowledge, which ultimately improves outcomes and satisfaction, and that we're really providing holistic care, so assessing not only their medical, their pathophysiologic conditions, but also their anxiety, lifestyle, medications, and symptom tracking. Thank you. Next up, I'd like to introduce Andrea Robinson, who's also going to give us additional pearls of wisdom from an allied professional perspective. Hi, good morning, everyone. My name's Andrea Robinson. I am the clinical program leader of our Atrial Fibrillation Clinic at OhioHealth Riverside Methodist Hospital in Columbus. So, again, I will be providing an additional allied health perspective and give my three pearls of wisdom. So, the first has to do with offering care through a standardized care pathway. So we know that, you know, atrial fibrillation care is really complex. It's also highly fragmented and variable amongst all the disciplines that touch patients with atrial fibrillation. And we know that there's documented gaps in use of anticoagulation referral for rhythm-based therapies the further we get away from electrophysiology or rhythm-based type provider. So, you know, at our institution, we realize the challenges in providing standardized care to patients with atrial fibrillation, particularly newly diagnosed atrial fibrillation, when we didn't have streamlined ways to get patients to a rhythm-based provider. And the referral usually is just left up to the discrepancy of the person who's caring for the patient with newly diagnosed AFib of where that patient is going to go. So to sort of mitigate this heterogeneity in care delivery, we use our dedicated atrial fibrillation clinic sort of as a funnel or a front door when patients are newly diagnosed with AFib. All of those patients are funneled through our atrial fibrillation clinic. The providers in that clinic use a very systematic fashion of evaluating patients for stroke risk reduction, rate and rhythm-based therapies, and risk factor modification. And then they make sure that the patients are aligned up appropriately with primary care, cardiology, EP, or a combination of all three of those things. So my pearl of wisdom is a single referral pathway for new onset AFib can help to deliver standardized care using an integrated team approach through an AF clinic. My second pearl of wisdom is what we've also heard about is using an integrated care model to deliver care for patients with AFib. These care models have been proven to reduce cardiovascular mortality and also hospitalization for those with atrial fibrillation. As we know, AF is an epidemic with increasing age of our population, which is more comorbid, but there's a lack of access to electrophysiologists. In the U.S., I think it's estimated only about 2,500 EPs for all of these patients. And so using allied healthcare providers really can help bridge that gap from the patient with AFib to electrophysiology. So using APPs to help expand access, using pharmacists to follow patients on class three drugs can also improve safety, and using RNs can help enhance patient education. And it really helps to take the weight off of the electrophysiologist when you're using all of these people on your care team. So just as an example, in our AFib clinic, it's 100% staffed by allied health professionals with APPs, RNs, and a pharmacist, but we have really close collaboration with our electrophysiologist and also a dotted line to our general electrophysiology practice. This does take buy-in and engagement from the physicians, so I'd say if the physician's in the room, a model like this to be successful, you know, at our institution, it's taken a lot of time with education, it takes your time to educate us to make sure that we are disease experts in AFib and to make sure we have the confidence to have these in-depth discussions with patients and to transfer that confidence to the patient. It takes a lot of trust and support to allow us to practice with that autonomy. But I do think that it's the best way to help bridge the gap with the growing number of patients with AFib to electrophysiology. My last pearl of wisdom is just to really focus on patient education. So you'll read a lot about education and the criteria document for AFib Center of Excellence. You know, I think sometimes we underestimate patients' ability to learn complex topics such as, like, disease pathophysiology. We know it takes a lot of time, but as we know, many, you know, many papers have shown that the more educated and engaged a patient is, the more likely they are to be adherent to therapies such as anticoagulation, which translates to less reduction in stroke. So in our center, you know, we have 50-minute visits in our AFib clinic because it does take time. That's not available at every institution, which I know it's not. You can consider bringing patients back for just a dedicated visit, either with an APP or an RN. Patients learn in many different ways, so we need to make sure we're meeting them where they are. So there's multifactorial opportunities. We use several apps to, you know, go through little videos and movies with patients to make sure they can understand how their CHA2DS2-VASc score is calculated, to understand where their pulmonary veins are located and how certain medications and procedures are used in the body. And we also want to make sure patients get standardized approach to education every time with every encounter. So we use an atrial fibrillation treatment plan, which ensures that all four pillars of care are addressed with each patient every time, and they sort of take this plan with them so they're engaged in the process. And that is it. Thank you very much. Thanks so much. I'd like to invite to the stage Dr. Bill Lewis, who will speak with us about the registry perspective. And I think this echoes what Jen taught us earlier, show me the data, right? So I think we're going to hear a little bit from Dr. Lewis in terms of the specific sources of data. So I don't have slides, so your refund check from the HRS is on its way, just so you know. I think everybody in that panel has talked about the idea of quality of care, and in fact, that's what the title of the talk is. And the pearls that come from that are really included in a lot of what everybody was saying. But quality of care does tend to come out as one of the pillars of how we're going to have a center of excellence. Okay, so now it's creepy that I'm watching myself on the TV, so. Okay. So the first thing is, the first pearl is you've got to measure it, right? So if you don't measure it, you don't know how you're doing. And the one advantage of a registry is that a registry organizes data collection. It can often be downloaded from your EMR, so you're not manually putting the data in. And you get to compare yourself to other institutions across the country or across the world. I'm going to sound like a salesperson today for the Get With The Guidelines AFib program, but the Get With The Guidelines AFib program came out of what we were observing as a serious treatment gap. So you remember, direct oral anticoagulants came out in about 2010 and 2011, but in a publication as late as 2016 in the Journal of the American College of Cardiology, the adherence rate to anticoagulants in patients with AFib was still only about 50%. So around 2014, we were starting to see this problem, and we put together the Get With The Guidelines AFib program. And in 2017, we did this wacky thing where we actually collaborated with the Heart Rhythm Society, and basically the program is a 50-50 program between the two organizations. And with 250 hospitals now participating in this program with 48,000 patients enrolled every year, we're seeing 99% adherence to oral anticoagulants in patients who don't have contraindications to anticoagulation. And this was a monumental change, because in most quality of care registries, we're not seeing this kind of number. So that pearl number two is, registries are an excellent source of real-world data. So we all look at randomized clinical trials, but not everything can be measured in a randomized clinical trial. So things where you see real-world problems, like off-label use of anti-rhythmic drugs, or data on women and minorities, which are commonly left out of randomized clinical trials, are included in these. There are also really interesting ways to advance the careers of young investigators in clinical research, and in the AFib Get With The Guidelines registry, we have 17 publications since 2013, looking at a variety of things, and we have a number of papers that are still in the pipeline. In fact, yesterday, we had a shark tank program to award the ability of a young investigator to actually use the database to be able to publish some very important information on patients who are elderly, and how they're treated with radiofrequency ablation of atrial fibrillation. Registries, the third pearl, is the registries demonstrate to the world your quality of care. And again, in my role as the salesperson for Get With The Guidelines, I'm going to tell you that in that program, 58 hospitals were recognized for their quality of care performance and are on the website, and they get to put badges on their own website to demonstrate that care. And I know that that sounds small, but at the end of the day, it's a source of pride, and pride is what produces quality of care. Looking at yourself, looking at others, and actually making changes in the way you practice so that you can celebrate success and demonstrate the quality of care you provide. So again, I appreciate the opportunity to speak with you this morning, and appreciate hearing the rest of the speakers. Thank you. Next, we will hear about some out-of-the-U.S. perspective, for some international perspective. Yeah, thank you, dear chairman, ladies and gentlemen. I do have slides, and it is good that I can remember the things I wanted to share with you. I will discuss a little bit the experience that we have encountered in Germany over the last seven years in certifying AF centers based on our German National Cardiology Society. I'm not sure if these are pearls of wisdom, so you may decide later on. In AF ablation in Germany is very prominent. We have 340 centers, 86 million people living in Germany, a total of 136,000 ablations. Two-thirds of them are atrial fibrillation ablations. Thirteen percent of the overall AF ablations in 2024 were done with PFA. One-third was done with cryos, so the majority was still done with point-by-point RF. You can see that out of these 340 ablation centers, our German National Society actually created a certification process, and so far, 103 centers are certified AF centers. There are lots of things that are involved in this, and I will just briefly go through it. The important thing is that this income passes around 40% of the overall AF ablations done in Germany, so they were done at certified centers. Fifty percent of these centers have an on-site cardiac surgery, and I will come to that later on why this is important. So we started off with trying to heal the world, basically. So we were trying to optimize patient care for every AF patient in Germany and creating an ideal optimized journey for AF patients, and there were some very good ideas how to measure this process and the maturity of this process, as you can see here, but in the end, we identified that this is way too hard for us in Germany, and so we more and more centered actually on a single procedure, which was AF ablation, so all the things that I will tell you are actually more AF ablation centers than AF centers, and I think this is a very important difference. One thing that we found in this process is, and we were working with different ideas that numbers count, so we were putting up a minimum volume requirement for being an AF center and get certification. This had no legal implications, so in Germany, every center who wants to do a single AF ablation will get reimbursed for that. It's different than in France, for example, where they have a dedicated number of procedures per center, and if you don't do that, you will not get reimbursement, and maybe there are some differences in output, but just the general idea with minimum volume requirements is that it's easily measurable and that, of course, there is a positive correlation between high volume centers and better treatment results. I will show you some of the downsides of this, and this is not cardiology, this is orthopedics, this is total knee replacements in Germany, and we had a mandatory minimum volume for getting reimbursed for total knee replacements in different time frames, and I don't think you can see my pointer, but I just wanted to show you that in the time where there was the mandatory minimum volume in place, you can see that the numbers of procedures dramatically went up, even though the number of centers were low, so everybody wanted to get these at least 50 cases, then the government decided to drop this mandatory volume number, and all of a sudden, numbers were dramatically lower, so they decided to put it back up, get another mandatory minimum volume, and you see the numbers are increasing, so there may be some negative effects when you think about identifying some requirements for certification. I just indicated that we actually wanted to make AF life in Germany safer, in this case, we did it for at least for the AF ablation procedures, so every center had to report their incidences of major complications, and you can see that there's really not so much difference in between low and high volume centers, these are the incidences of major and minor complications that were acquired, and one thing that came out of this was actually that nobody knew what to do with patients who had atrial esophagy or fistula, and so in Germany, we set up a fistula hotline, and I will really recommend you, if you have any problems with the esophagus in an AF patient, nobody really knows what to do, maybe Philipp Sommer and myself, we have a long experience in working with these patients, we may just a little bit know more what to do, consult on diagnostics and treatment, and it is more a process of trying to help physicians dealing with this complex and severely severe complication after AF ablation, and this was the inputs into the hotline, so it's not like there's 10,000s of patient inquiries, 30 cases were discussed with us, five edges of a geofistulas, and you can see that even with doing everything we could, two of these died, but two others were successfully operated, so it is just a process, what we learned, and I think this is one of my pearls of wisdom, if you have very, very rare complication, try to focus on experts who know about this and can help anyone in consulting with this, so in summary, AF centers of excellence should strive to optimize AF patient journey and care, including all entities that manage AF patients, and this is important, if you do not have an AF ablation program, you must, as a center of excellence, have a cooperation with one, but you do not have to have it in place on site, in Germany, the process is centered around AF ablations, not sure if we're really happy about it, but this is the way it went, if this has any influence on the general management of AF patients, we don't know, and pathways and standard operating procedures, in our experience, are very, very important, managing AF ablation complications and dealing with these to increase safety for the patient. Thank you very much. And next we're going to hear some perspectives from a non-EP physician. Thanks, Janice and Tara, for moderating the session, let's see, hopefully it's going to start, double-click, no? It will come up, you have to be patient, though. Okay. You have my disclosures, I'm a stroke neurologist at Massachusetts General Hospital and Harvard Medical School, so I think I'm the only non-EP, non-cardiology physician here, this is a more detailed version of my disclosures, my research funding mainly comes from NIH, but my hospital receives some research grants from industry partners as well. So the overarching pearl of wisdom today is to do a lot of operational collaborations with vascular neurologists and other specialists for the detection and optimal management of atrial fibrillation patients. My colleagues very nicely explained what a atrial fibrillation center of excellence entails. I've been on the writing committee of the consent statement that has been discussed multiple times in previous talks. I'm not going to go into the general aspects of this, how to develop it, what are the skills needed, et cetera. I'm going to give you three pearls of wisdom, very specific, about how cardiology and cardiac electrophysiology physicians and advanced practice providers can do to collaborate with stroke neurologists and other specialists to improve atrial fibrillation patient care. So you guys I'm sure have heard of ESUS, embolic stroke of unknown source. Essentially a patient sustains a ischemic stroke, all of the baseline workup is done, but no cause is found. So this is called cryptogenic stroke, ischemic stroke of unknown cause, and if it's not a lacunar stroke, then it's called embolic stroke of undetermined source. Large randomized controlled trials, many of them, show that anticoagulation is not better than aspirin for these ESUS patients, even when atrial cardiopathy criteria are present. So anticoagulation only helps if we detect atrial fibrillation. And this is a subgroup analysis of the Artesia trial that was published by Ashkan Shomanesh from McMaster's just a few months ago. It clearly shows that device-stated atrial fibrillation, when you find it in people with a previous ischemic stroke or TIA, then anticoagulating these patients make a huge difference. You decrease the risk of a recurrent ischemic stroke by about 60%. So we need to, especially in people who sustain an ischemic stroke or TIA, without a clear cause, we need to detect atrial fibrillation, we need to make an effort to detect atrial fibrillation. We have a lot of external long-term monitor, insertable cardiac arrhythmic monitor, and it's an excellent way for cardiac electrophysiologists and stroke neurologists and other specialists can collaborate to improve the care of a patient with atrial fibrillation who doesn't know about it. This is the first pearl of wisdom, to develop operational collaborations with vascular neurologists and other specialists to provide long-term rhythm monitoring for patients with ischemic stroke or TIA of unknown atriology. The second issue is about people with non-atrial fibrillation who has ischemic stroke despite using oral anticoagulant. The thing to remember in this patient population is that, unfortunately, their risk of a recurrent ischemic stroke is extremely high, and changing the brand of the direct oral anticoagulant or switching Doac to Warfarin or Warfarin to Doac or adding aspirin, none of these things make any difference. So in these patients with atrial fibrillation with ischemic stroke while using oral anticoagulant, the annual rate of recurrent ischemic stroke is 8.9%. This is about 10 times higher than what we have seen in phase three trials of direct oral anticoagulants, and this has been proven over and over. This one is from the continued follow-up of the main randomized controlled trials. My good friend Jeff Healy put together data from this combined AF cohort that included all of the RCTs of Doacs, and in patients who sustained ischemic stroke, when you followed up on them, the annual risk of ischemic stroke, recurrent ischemic stroke was 7% regardless of what you do. They were all on anticoagulant. And we have proven the same thing in a much larger patient population in the United States as well. So if a patient with atrial fibrillation sustains an ischemic stroke despite using oral anticoagulant, of course we need to ask about adherence, dosing, and such. But we also need to do non-cardiac workup, brain MRI, neurovascular imaging, additional testing which might include hematologic testing. I highly recommend considering testing for antiphosphate antibodies which require Warfarin if they are present in such patients, and certainly further cardiac workup. So this is the end. A lot of times we don't find any concurrent etiology for such ischemic strokes, in which case we should enroll these patients who sustain an ischemic stroke despite use of oral anticoagulant in the setting of atrial fibrillation. We have LAOS IV trial that's going on worldwide, ELAPS trial in Switzerland, and Occlusion AF trial mainly based out of Denmark. So that's also another excellent opportunity for stroke neurologists and cardiologists and cardiac EP to collaborate. This is the pearl of wisdom number two, develop operational collaborations with vascular neurologists to perform a detailed workup for patients with ischemic stroke or TIA while using oral anticoagulants and enroll them into ongoing RCTs if appropriate. Third, last but not least, oral anticoagulants increase the risk of intracerebral hemorrhage anywhere between two to five-folds, especially even in very low-risk atrial fibrillation patients. And mortality of intracerebral hemorrhage related to Warfarin, Apixaban, and Rivaroxaban was 45 to 50 percent in Aristotle and Rocket AF. There has been multiple trials of atrial fibrillation patients who survived a brain bleed, and these patients were randomized to anticoagulant versus non-anticoagulant, and all of these trials clearly show that the rate of repeat intracerebral hemorrhage was exceedingly high among those patients, up to 10 percent in the anticoagulant arms, and the majority of these patients died. So that was shown in Sostort, and in Apache AF, all of the intracerebral hemorrhages after the first ICH occurred in people who were put on anticoagulants. The more recent study, Prestige AF, showed an 11-fold increase than anticoagulants was restarted after intracerebral hemorrhage in atrial fibrillation patients. There are also a lot of markers that predict the risk of intracerebral hemorrhage. So intracerebral hemorrhage being such a deadly condition, especially when it happens on anticoagulant, we need to make sure that we consider a different approach to stroke prevention in those patients, and the most recent Heart Rhythm Society, American Heart Association, American College of Cardiology guidelines clearly mention spontaneous intracranial intraspinal bleeding due to a non-reversible cause, which is the case in more than 95 percent of intracerebral hemorrhages, as a direct contraindication for long-term anticoagulant use, and they recommend left-of-the-appendage closure in those patients. Hence, the pearl of wisdom number three, again, we need to develop operational collaborations between cardiac and acute physiology and vascular neurologists to plan for left-of-the-appendage closure in AF patients who are at high intracranial hemorrhage risk. So that's the end of my presentation today. I'm very happy to take questions. Thanks for attention. Thank you very much. The floor is now open for questions. I'll invite you to come up to the microphones on the side. I will start us off with one question from the audience. The first question is, with respect to data collection, what variables not routinely in procedural notes, EMR, are most useful for the center of excellent data analysis? So I think this is a question that's broad enough for all our panelists here. Let me start with Bill, and then I will also ask the rest of the panelists to chime in from your perspective in terms of data collection. What data that's not routinely collected in procedural notes, EMR, or routine clinical documentation that we should be sure to include in the prospective data analysis for center of excellence sake? So do you, like, have four hours to do this to answer this question? I think that, so we collect a lot of information so that we can understand comorbidities and things like that. So the data that we collect is extensive. I think the critical pieces from our standpoint is, first of all, were they discharged on anticoagulant? If not, what was the reason they were not discharged on anticoagulant? And we try to scrutinize that as much as possible. I think that we want to know what mode of treatment the patient's being treated with. So are they being treated in rate or rhythm control mode? And if they were in a, and then what were the procedures used during the hospitalization to get the patient back in sinus rhythm? And we also have a specific ablation part of the program which looks at procedural things like what are the techniques you're using for both your anesthesia, what are the techniques you're using for pre-procedure thrombus evaluation, what are the techniques you're using, are you doing it on an anticoagulant? If so, what's the anticoagulant? And then the other issues are related to success of the procedure. Do we collect information on isolation? We collect information on scar burden. We collect information on procedural complications and then outcomes. And then we're rather unique in the fact that we have a follow-up registry at 90 days to see whether or not the patient's still back in sinus rhythm or not, or whether there are any further complications. Is that answering the question, I think? Yeah, that's fantastic. I'd like to invite the other panelists to chime in as well, and I'll also say a specific invitation for Tom to also give us some perspective in terms of in Europe, are you guys using a registry to collect data for your center of excellence? If so, how may those look similar or different from what we can also use in the United States? Yeah, I think it's a very important point to not only do the ablation on the one side, and some centers tend to do that, and then never follow the patient up, but you have to have a clear information on the follow-up of your patient to also relate that to what Bill just said, all the information from the procedure itself, and try to optimize outcome. Now, this is not always done in an electronic form, so we are not able to integrate all the information from smartwatches, from any device that you can document your rhythm on, so we're still working on that, but I think as in science, we turn more and more into not AF as a binary, but also more as a burden problem. We just have to make sure we can measure that, and today in Germany, we're not able to decisively look at AF burden after all the procedures, and so we're working on that, but it's a work in progress. Yeah, I also want to call out, too, that going back to working in silos and creating redundancy, I think a lot of the databases that we have, there's multiple databases, right, so we have our own internal databases, we also have registries, and they're variable registries that look at different data points and different outcomes, so harmonizing those data points that we want to look at is really critical, and it's difficult to do this, particularly in the U.S., because we all function with different EMRs, so it's not like we can data share as easily as we would like to, so ideally, we come up with the data that we want to collect, and then the data and the outcomes that we want to look at, and also, we have a centralized location that are non-PHI related that we can all data share and learn from that data. Yeah, I think that's why, I mean, the guidelines are essential to doing this, right, so you understand your measurements based on what the guidelines are demonstrating to you. Also, in follow-up to Thomas's point is, we, you know, we, a long time ago, we had our surgeon who was doing maze procedures, and, I mean, I don't know what he was doing, I mean, he made a couple clips here and a couple clips there, and he said, I have a 100 percent success rate, and, I mean, you know, again, it's what is, what's the term, you know, within normal limits is really WNL, or we never looked, I mean, I think that's the, if you don't look, you think you're, you think you're perfect, right? Yeah, thank you all for your opinions on this. I think you have to start with the guidelines, and also, using the available registries that are out there is important, but ultimately, it comes down to each place might have different things they need to measure, depending on what their goals are, so if, in my place, let's say, you know, it takes 90 days to get a patient in for atrial fibrillation from diagnosis to seeing a specialist, and we want to cut that down to 30, I mean, ideally, I want it much less than that, but starting in increments, you need to measure what's your access time, how long does it take a patient from time of referral to being seen, and then, you know, I agree that anticoagulation should be, all of us should be measuring that, that's a standard of care, but that's how we would approach it. I'd like to piggyback on that from the allied perspective and say that, you know, I think it's important to follow ease of access, so how soon are they being referred, how soon are they getting their ablation procedure, what is their compliance for anticoagulation medications, and then, what is their long-term follow-up and, you know, goals and outcome, so not only focusing on, like, the registries, but also patient-specific and center-specific. One thing I would caution is that it has to be a reasonable amount of data, like, you can't, if you have five pages of data collection for every patient coming in, you're not going to do it, so it has to be, I think, some reasonable amount of data that you start with. But definitely, you have to get some data for follow-up patients, and I mean, I just wanted to address that point, that, I mean, the motivation for being a center of excellence can be intrinsic, but can also be extrinsic if it is related to reimbursement, and this, in the end, we need to show that we are dealing, we are treating patients effectively, and if effectiveness then translates into different degrees of reimbursement, we just have to be aware and have to work on this process before someone else does, and we end up with a solution that we don't want. We have one additional question from the audience. I think I know exactly how Dr. Silverstein is going to answer this. What resources would you recommend for a PA tasked with developing an AF specialty clinic? It's like a paid pitch right there. Yeah, I think, as we've mentioned, CardiQ.org is a great resource to start, and if you don't find the resources there, there is the, there's a group chat function, you can ask questions and receive answers, and, you know, when those questions are posed, those who are answering can post their stuff on CardiQ, and it's going to become, it's already a great resource, it's going to become better and better as time goes on, as more people share what's worked for them. There's another question. Is most of your data collection automatically pulled, and if not, who is manually collecting this data from your clinic? Great question. So I'd say in my institution, it is part of the role of the AFib clinic staff to collect our data. So our nursing staff is tasked with pulling data from EMR, the APPs, when they're writing the notes, we have them very templated, you know, we have it pretty delineated, what we're collecting, to make it easy for them to pull it out, and then, unfortunately, it is a manual collection. Despite many attempts at trying to use EMR and make EPIC work for us, it's really challenging, even, you know, when you go and you audit some of the pre-populated chats, FAST scores, they're based off of poor information going in from the beginning, so for us, it's been a manual process. I'd love to hear if anyone's conquered that in a better way. I'd love to give you a good answer to that, I think, but 40% of our data comes in, it flows in through a third-party software company that does that, the rest of it is manual. Another reason for this AF Center of Excellence criteria document was so that we can also engage administration, and so this is a conversation for each place, each institution, to figure out how are you going to collect the data, and that might mean that if your institution wants to be an AF Center of Excellence, which we all really should, then it may need that you hire someone for data collection, from the quality department, and what it results in is better patient care. It's going to be better for the patients, number one, but also better for the healthcare system and the payers in the area. I would echo that. That was one of our biggest wins, was creating a solid business proposal for a dedicated quality team for our Heart and Vascular Institute, because we wanted to own our data and to really look at what we wanted, so it is, though a manual process, it is making the case for that resource. If quality truly is a priority for our healthcare system, then we have to have the people that are trained and looking at that quality from that perspective. We are at the end of our session. I want to thank all the speakers. I'm very impressed at having a large panel. We actually managed to stay on time, phenomenal, and I think as the audience will appreciate, this is really being a fantastic range of perspective that's really come together. I hope you will all go and pull up this document that's quite comprehensive. I think it will very much help your practice, and with that, I'd like to close the session and thank all of you for being here.

quality of care

centers of excellence

atrial fibrillation

multidisciplinary collaboration

standardized protocols

patient-centered care

AFib management

clinical registries

anticoagulation guidelines

virtual healthcare