Well, good morning, everyone. I think I'll start first just by saying thank you so much to Atricura for the invitation to be part of the meeting this morning. What an amazing conference so far. I'm Mike Riley. I'm an EP with WellSTAR in Atlanta, and I'm accompanied by Karen Martinelli, my nurse who anyone who knows Karen knows that she's the real brains of the operation at WellSTAR. And I can say that at WellSTAR, we're a fairly large program in the Atlanta area. We have over 100 referring cardiologists. We have seven full-time EPs and three cardiac surgeons. And one of my surgical colleagues is actually here, Dr. Theresa Liu, in the audience today. And we were very early adopters of the convergent approach. We performed our first convergent ablation in 2013. And at this point, we've performed well over 500 convergent ablations. And it's been a pretty wild ride for the last 10 years or so. And I can honestly say that our interest initially in the convergent approach grew out of frustration, frustration with ablation outcomes. We know, as EPs, we're very effective at treating paroxysmal AFib, but the reality is the majority of our patients do not have paroxysmal atrial fibrillation. They have more advanced disease. And we also know, as many of the speakers have pointed out earlier this morning, that an endocardial alone approach to more persistent advanced patients is really not adequate. So it's been kind of a wild progression over the last 10 or more years, and it's been amazing to see how we've grown really into a more comprehensive AFib program over the last decade. So we'll get the chance to talk a lot more about that. But first, I'll turn it over to Karen, just to review some of our protocols and patient throughput. So I'm Karen Martinelli. I am the nurse coordinator at Wellstar Kennistone Hospital. I'm a master of all trades, so I round clinically, I see patients in the office, I do all kinds of things. Wellstar has been a program that we started probably back in 2014. Every day it grows, every day it changes. You know, our limiting factors have become very different than what our limiting factors were when we started this. We have two AFib navigators, we have seven EPs, six nurses, five mid-levels, and the best scheduler that ever walked the face of the earth. We do a half-day designated AFib clinic. We see new patients in that clinic, period. We see new AFib patients. These patients are typically worked up. They're coming to clinic with the intention of needing a procedure, not, we can no longer accommodate just having random AFib patients come to the clinic, so it's become a designated procedural type clinic. We see an average of probably more than 20 to 25 AFib consults per week at this point. We do over 500 AFs a year. We are a 700-bed regional healthcare facility. We do everything. You know, MAISes, cardiac surgery is a partner of ours. We're such stepchildren that they actually moved us into the same office with the heart surgeons, so we're now all in the same space. I talk about a heart team approach to treatment of atrial fibrillation. This concept for a long time was like flying the space shuttle, right? But what we realized over time was it really improves the clinical outcomes. It gives us process improvement based on our own clinical outcomes. We use EMR, internal messaging, a scheduler. We are able to track our patients and go back and forth between the surgeons and us and comments that way instead of sending text messages and instead of making phone calls and nobody knows the phone call happened because both the surgeon and the EP were in a case when it happened. We have reciprocal referral processes now to where we see most of the CT surgery patients that have AFib, even if they're going to have a concomitant procedure, so that we can help them to follow the patient along going forward so that if they have any typical flutter or they have a problem, we're already on board. We'll see them in the ICU if they need us to. It is really come back around. We send them our, we send Dr. Liu and her partners, the Mitrals, but again, EP's involved on the front side, so we're not dealing with a lot of the issues that we dealt with before. We promise cardiology that they get their patients back. We don't follow cholesterol, we don't follow blood pressure, EP follows arrhythmias, and we've made that very clear with our teams that we're not keeping them forever just for their AFib. It really has shown us a significant improvement in patient satisfaction scores. When you see guys that consistently have press gainings in the 97th percentile that are as busy as these guys, it really speaks to what we've been able to accomplish with these programs, increases revenues for the hospital and the docs and everybody else. I know nobody ever talks about that, but when the patient satisfaction scores are high and the patients are happy, the docs are happy, the business is lucrative, everybody is in a good place. Dr. Riley can speak to this, it puts EP in the driver's seat for long-term management and long-term follow-up. Surgeons, most of you guys I think are surgeons, but you guys are doing a lot of other things. It's not just managing AFib. It gives us the ability to follow these people long-term, to get them back for a redo ablation or a touch-up. We do a lot of de novo cases. I think we do. I would say that one of the most beneficial things that has grown out of our AFib program over the last 10 years is this reciprocal referral process that we have with cardiac surgery. Like Karen mentioned, any time a patient with atrial fibrillation gets admitted, let's say for CABG or mitral surgery and seen primarily by CTS, it triggers an automatic consultation with EP. We see all of these patients. It keeps us busy, but I think there are certain benefits to that. They look to us actually for recommendations on how to manage these arrhythmias, to make recommendations regarding ablation strategies. Most importantly, these patients, they don't slip through the cracks, they're not lost in the process. We make sure that we have follow-ups set up for them. If they need endocardial ablation or mapping, then that's set up before they leave the hospital. Again, it just speaks to the importance of collaboration among the teams. Again, I think Tara, everybody needs to think about it, because when you schedule the first part of a convergent, we see the patient, we send the patient to the surgeon, the minute we get a message back that that patient is scheduled, we're already in the process of scheduling part two. We're scheduling our side. We do that, from our perspective, about six weeks out, four to six weeks out. We schedule all the appointments in the interim, so if somebody lives in North Georgia, that patient doesn't have to drive three hours to come back and see somebody, and then see somebody again, and then see somebody again. It puts them in a position where they have all of their instructions, they know what the plan is, and we typically don't lose patients. They don't get lost in the shuffle by doing it that way. It's all process development, coordinating schedule. From the last point, this is define your cardiac surgeon and your EP responsibilities. We take care of them in the ICUs. We take care of them on the floors. We manage drugs, and they typically manage their drains and their operative portions. We have developed quite the relationship with the CT surgery APPs, and have developed anticoagulation protocols, and everybody is on the same page when it comes to these patients. We do hybrid. We do opens. We do concomitants. As a team, we do them all. It's not just a piece. We ensure that all the cardiac testing is done. Usually they come from cardiology with their echo, their stress test, the basic stuff that they need, but we make sure they get the CT, the MRI, if an IVA hybrid is anticipated. They do the pre-op testing because they know and they want more inclusive testing than we do. This is where we talk about appointment scheduling. Appointments and procedure scheduling are left to our expert. She is an expert scheduler. She can coordinate this stuff from here to eternity. I do not schedule appointments. I do not schedule these procedures. I take care of the patients associated with these procedures. Determine how your follow-up schedule is going to go. Really stick to it for ablation patients. We see everybody still at two weeks. We have a pre-op set up for them before they are ever done with their first part of their hybrid procedures. The pre-op is an APP visit. Second part of the convergent is already scheduled, and it's all in one visit. Determine your follow-up schedule and make sure the follow-up is all done on the front side. Everything is scheduled on the front side. The patient will come back. A lot of these patients get the first part of this ablation, go home and say, I'm not doing this. I have already done this first part. Why am I coming back for a second part? They know on the front side that they have to complete this process. Certainly we follow all of these patients post-op. I think a key take-home point that I would mention is the fact that in order for a program to be successful, it's vitally important for you to have someone like Karen, a nurse navigator, because especially in the beginning, there are so many moving parts, right? And patients can get lost in the cracks. I remember very early on, we would schedule patients for convergent ablations, and they would have their epicardial portion, but somehow were unaware that there was a part two to the procedure, and then we would find them sometime later. So that was a disaster very early on. We knew at that point that we had to be more organized, and I think you'll speak about the importance of having an EMR system where everything is tracked, so we'll get to that as well. So like I said, I mentioned this, we don't text, we don't, we call because Dr. Liu likes to see the maps, and we like to communicate, and again, we're in the same office. So it's easier for us sometimes, but we use EMR for all of our communication. For an EPIC, the referral goes into EPIC. If there's an AFib clinic referral, it goes to the AFib clinic team, the AFib clinic team decides that that patient needs to be seen in an AFib clinic or standard EP clinic. It's a little bit cumbersome sometimes, but it keeps the patients that are actually coming into the AFib clinic procedurally based. We don't mind if somebody needs an AV node and a pacemaker, but that's probably something we can handle in a regular EP clinic. Is their patient appropriate for us? All of our communication, and I'm going to show you examples of this communication, are basically done in EPIC. So Dr. Riley here has sent a message to Megan, our scheduler, to me, and to Dr. Liu, and we send it to the surgery schedulers, the surgery schedulers schedule it and call us, let us know in EPIC that the patient's been scheduled, and it's done, okay? So we know, and everybody knows what the process and the plan is. These are just encounters. Now, these encounters go to the pre-cert people, these encounters go to the billing people, these people, this encounter will go to everybody that's going to touch this patient so that they can start the process. This is even copied to the scheduler for the CT scan or the MRI, so that the CT scan and the MRI scheduler calls and makes sure it's pre-certed. So these are just some examples, no he said, she said involved with any of this anymore. This is all up front, and if it's not read, you can see that it's not read. We even communicate with our patients this way. So when you look at this, this is a MyChart message. These are pre-op instructions that actually go to the patient. These are the discharge instructions in addition to the pre-op instructions that go to the patient in the chart. We make a follow-up call to make sure that the patient has read it, you can actually see at the bottom if they have or they haven't, so we usually check within 24 to 48 hours. So they get it all in writing. They get the discharge instructions for their procedures at the time of their pre-op with the surgeon so that they know what they're gonna expect. And for some of these folks, what I've done with this is when they leave the hospital, they get it again. And I've written on this piece of paper because a lot of these folks are just simple people. And if you put appointments at page 18 and 19 in Epic when the patient goes home, they're never gonna see it. So there's a little sheet we give them. They have everything written down. They can stick it on the refrigerator. They know where to be, what to do, and how to do it. So we're using EMR almost exclusively for communication on these patients so that they are not lost in our system. And you'll see a lot of people copied when you start looking at these, but it's the only way to ensure that everybody is doing their piece in a really large institution. Are there any just general questions? So let me start off for both Mike and Steve. You have separate programs, various stages. How did you actually, or what was the timeframe in terms of getting a program off to where it is now? Or let's actually put it a different way. What words of wisdom, in a nutshell, would you say are the pertinent points that needs to be addressed? I would say that we started off very slowly and gradually built up volume and experience. I think in the beginning, the obstacles that you may encounter, sometimes it's a physician buy-in issue where you can be the most excited EP in the world about convergent ablation, but if you don't have a surgeon champion as a partner to help perform these procedures and take care of these patients, then you're not gonna have a successful program. So that's key. And I think Theresa can probably address this as well, but one of the things that helped us in the beginning was actually going to an atricure course very early on together and to talk about convergent hybrid ablation and basically to help imagine what was possible. And then I think over the next few years, the program built up and then it's evolved to include left atrial appendage management, ligament and marshal, other things. But I think increasingly we realized too that hybrid ablation, a big part of it is the convergent approach, but it's certainly not the only approach that we take. And so we use different approaches for different patients. As we mentioned, a lot of these patients are seen by the surgeons first for another reason. They get a surgical afib ablation and then we take these patients back and do endocardial ablation. And so it's almost like a hybrid ablation in reverse. You mentioned that you have quite a large EP group. How did you actually get them on board? We were very lucky with our group. I mean, I think that the frustration I talked about with ablation outcomes was shared by the entire group. Before convergent, we were all taking different approaches to these patients. People were doing CAFE, people were doing lines, box lesions, things like that. But I think across the board, everyone was pretty excited about the data that we saw for the convergent approach and we were all early adopters. It's Steve and Kent, I see. For us, I think we started talking about doing convergence in 2016. I think some beginning of 2017, we actually went to Tampa to watch these guys, the heroes. Watched them do a couple of cases and I kind of was like, well, if he can do this, I think I can too. And I think we did our first case probably shortly thereafter in the spring of 2017. And as we kind of talked about before, we kind of, I wouldn't say limped along, but we had cases. I think one of the big things for us was that Kent was the EP hero for us and he was our champion in the beginning and he and the other, I hate to use the word senior, but more experienced EP were big contributors and big believers in the program and the younger guys were kind of waiting and watching and seeing how it all went. And I think once we started seeing the maps in our conferences, they bought in. So then the entire EP group bought in and that took another year and a half probably to two years and then we were able to then expand the referral base to general cardiology, primary care, kind of sitting down with them and educating them to what we were doing and what it meant and that was probably the final push. Yeah, and I just want to emphasize, I mean, it's being talked about, but I think that having a regular cadence of that heart team style meeting really was critical for us to get the program off the ground. I think you talked about there was sort of a referral here and there, but when we started to sit down together as a group of surgeons and EPs and talk about patients on a regular basis, it wasn't like, oh yeah, I should send, that regular cadence was really critical and initially it was like, well, we don't have any patients to talk about or their order sets or protocols or whatnot and then Steve mentioned, I think for some of the, some of my EP partners that maybe were a little skeptical, I think seeing the follow-ups, the case presentations and the follow-ups and seeing the results, I think helped them sort of start to get to the point of like, well, okay, maybe I'll send my third or fourth time ablation to, maybe I'll send my second time ablation to, hey, this might be a good patient to actually send for de novo. Or the guy with the BMI is 60. Yeah, we have tried over the years to find his upper limit on BMI as well, but I think I just really want to emphasize that that really for us, I think has been key in the whole process is just having that regular communication, that back and forth. And I would say just like what you guys see, once we started doing this collaboration, all my mazes would have EP follow-up. And then once all my mazes started getting EP follow-ups and the concomitants, then my surgical partners would like, well, is Peterson doing that? Well, why aren't we doing that? And so now all of our concomitant cases as a team are all getting EP follow-up. They're all making sure that if they do, you know, if they have a breakthrough or something that they're going back and getting studied, that somebody's following their amiodarone, they're following their anticoagulation, all those things that in general get kind of missed or no one wants to touch them, right? We've all had that senior partners who don't want to touch anything that has to do with the antirhythmics or anticoagulation. So for us, it was a big goal and a big achievement, I think, to make sure that all our concomitant patients are being followed appropriately, getting seen by EP. And again, that's sort of that quid pro quos like we saw earlier today. That was a huge deal. And there are a few advancements along the way that come to mind that really improved our outcomes. I mean, I think the first one that comes to mind is switching from what used to be the transdiaphragmatic approach to the ablation, which was really a nightmare for us. I mean, we saw so many hernias that needed to be repaired after that. And when we switched to the subxiphoid approach, all of that went away, right? We used to see tons of inflammatory late pericardial effusions, but the use of, you know, interoperative steroids and management, it's been several years, I think, since we've seen a fusion, really. I mean, it's been really rare, knock on wood. And then in the beginning, we were doing all of our convergent ablation same day. And, you know, we've switched, like most centers now, probably 70, 80% are doing staged procedures where we wait four to six weeks between the epicardial and the endocardial portions. The same day was fraught with issues. You know, a patient spends eight, nine hours under general anesthesia. And then there is some real benefit, I think, to allowing, you know, the epicardial lesions to mature. And when you perform endocardial mapping after several weeks, I think you get a much clearer picture of what is there and what needs to be touched up and done. So all of those things, I think, really helped us. Are there other questions? Okay. Let me just ask you something, Michael. You have about 500 patients, you know, off the top of your head. What is your success rate? Well, I mean, I think we've begun to look at this. In a year, we're about 80%, okay? And it's the same standard. You start to see, once you get to the four to five mark, you start to see a trend down. But for the most part, I mean, a year is right at the same paroxysmal priority standard. And the data follows closely, I think, with the results of the CONVERGE studies. Okay, great. Okay, any other questions? Okay, what we're gonna do is have a short video. Welcome to the Pets Lab. We're in Minnetonka, Minnesota, which is one of our atricure corporate offices. We have a world-class training and education team that's ready to take as many people through here as we possibly can. So we're really, really excited to have this new facility available. This is our first fully built simulation lab so that we can train physicians, sales, internal people, as well as work in conjunction with engineering to help keep pushing innovation and education to make sure our patients get the best treatment possible. What really, really makes this cool is being able to have experts in the room to talk to our customers. And our commitment as a company to education, this is a good manifestation of that. It's exciting that everything's already set up here where we can have customers come to us and are able to really learn hands-on. We can customize the training for whatever their needs are, whatever they're experiencing. We can just tailor it to whatever they need. As you see, this is the device, right? Flex Mini is 60% lower volume than the next lowest profile clip on the market. From an engineering standpoint, we're gonna be supporting the use for the clinical education team, the sales team. So when customers come in, we can provide any technical input or expertise that would be required. We can also use this lab for working on developing new products and having quick iterative conversations as we move through the development cycle. One of the best things that we have here is that it's completely combined with the engineering lab and everyone else around us. So as we continue to innovate, it's really nice to have an area where we can all test the new products and work in conjunction with the engineers so that we can give our live feedback as people who are in the OR all the time. Having everything in-house allows us to go through the entire gamut of our product line and also the entire gamut of the procedures that we do. In addition to this level of hands-on training that you can engage in while being present in the lab, we can also engage individuals remotely. They can have a sense of almost being present in the room without being here. With Teladoc, they're able to see what the physician is seeing on a screen as well as what they're doing with their hands. We used to train physicians on cadavers and we have gotten away from that by having a model that is extremely realistic. To me, and what I've seen, it's the most advanced training you can get without getting a live person. We work in a field where healthcare professionals who provide the care engage in continuing education on a regular basis and being able to support procedures where our device are being utilized, it's important that we engage in continuing education and keep our learning sharp. I just love the fact that we as a clinical team have an office now where we can really drive home our education and our training for us too. We're trying to be at the forefront, we're trying to be ahead of our physicians, ahead of our doctors, and now that we have a full simulation lab where we get to play around as well, that just benefits us and allows us to stay ahead of the game. Thank you. Okay, thank you, our professional education team. And obviously that was an invitation for any of us to reach out to them to use it. Thanks.

AFib program

convergent approach

electrophysiologist

nurse navigator

patient outcomes

collaborative heart team

Atricure training lab