What I thought I would do today is not just talk about our evolution of the convergent procedure from what we've, our nomenclature is convergent 1 to convergent 2 to convergent 3. And there's nothing proprietary about that. There's a lot of people out there that are doing very similar things. So we, this is nothing to do with that we're the only ones doing this. There's a lot of people, like I said, doing a lot of this. But I thought I would also touch on the journey between Kevin and I's work marriage, which is just maybe a more important journey that we've been on as part of our convergent journey and our open concomitant case journey. So to start with Kevin and I, here's the two of us playing in a sandbox on the left side. And that was basically in 2010 when we started our first convergent procedure. And Kevin, we basically met each other when he came up to me and said, would you be willing to try this? And I said, sure. And over the years in 2024, here's the two of us actually playing together in the same sandbox and playing nicely and having a nice time together. And it's translated now in 2024 to basically within our system, our hospital, multiple electrophysiologists, multiple surgeons, almost everything afib related, we do together. So it started the impetus of our relationship between two specialties that were very far apart in terms of, we know our structural heart teams and our revascularization teams, but there was really no such thing as a arrhythmia team. But starting with the convergent procedure as the nidus, now we've made that to almost everything we do. So the convergent started this. We'll talk about how we've moved on from the convergent from our first iteration to the second to the third. In terms of our concomitant Cox-Mays forework, we for years have interacted together. So it's very much a quid pro quo because I need every aspect of Kevin in terms of what I do from an open standpoint to make sure that what Dr. Cox has so elegantly described over the years, that in my hands, I'm actually reproducing a similar lesion set. So we've done a lot of electroanatomic mapping of our concomitant open maze work. When something new comes out, like the encompass clamp that we'll talk a lot about tomorrow and I hope to see everybody tomorrow, but we educated the patients right off the bat. We're going to use this new clamp on you, but you do know that you're then going to see Dr. Mercati afterwards and he's going to map and we're going to make sure that what we think I'm doing with this particular clamp is actually showing up in an electroanatomic map. And our mapping led to some procedural changes that we'll go through in tomorrow when we talk about concomitant things. And then that's led us into some novel iterations of Dr. Cox's original maze that may be something that's more efficient, maybe more adoptable. And that took Kevin and I sitting in cadaver labs, poring over maps that we had done and basically then implementing that from a clinical standpoint. So back to our convergent evolution as opposed to our relationship evolution. The first procedure, and I always love this graphic on the left because it shows the beautiful rectangle swatch of tissue along the posterior atrial wall that we are supposed to ablate as surgeons. I can tell you I don't think I've ever produced a map for Kevin that has looked like that beautiful rectangle. And I think the reason is because the right side of the slide that everybody has different pericardial reflections and folds and you just can't every now and then we'll get up as high as we want and we'll get from right to left as much as we want. But most of the time, the pericardium, at least at a minimum, as you get towards the left side of veins, really comes down towards the left inferior pulmonary vein. You can't really get high up on the left side. And that's just one anatomic variation. There's so many different ones that the bottom line of this is that when this first came out, we kept thinking to ourselves along the terms of a maze concept. And what we wanted to do was, okay, well, if Kevin's going to isolate the veins, then I guess I need to somehow connect the superior vein and the inferior vein. And then everything you've seen from Dave and Nitesh, Randy, about the posterior, the importance of the posterior atrial wall, all of that literature was coming out around the same time. And CAFE lesions and reentry circuits and all sorts of stuff. And we as a surgeon, I said, well, if I'm going in there, I may as well just take everything I can along that posterior atrial wall. And I think even to this day, we believe that's probably the most important surgical concept. The concept of the CONVERGENT procedure is as much posterior atrial wall substrate ablation as you can take care of. Now, we did originally, the CONVERGENT in 2010 was basically radiofrequency. Dave told you about the CONVERGE trial, which was all radiofrequency as the endocardial energy source. And with Dr. Sud, Kevin, our teams, we published in Circulation and in Jack. We had used cryo from the get-go. And so did Dr. Sud from the get-go. And so we published the safety efficacy of different energy sources from an endocardial standpoint. The epicardial standpoint still is the same rate unipolar radiofrequency energy that we deliver. And in 2024, Kevin is primarily using for his portion of the CONVERGENT procedure PFA. He's not replaced the CONVERGENT procedure with PFA, but he's using that as his energy source currently to touch up and do everything that he's always done as his aspect of the hybrid procedure. This has always remained, and we hope remains, a hybrid approach to longstanding persistent atrial fibrillation. This is our electroanatomic maps post-epicardial on the left. And then Kevin making the map look as good as the maps you've seen from Dave and everybody else this morning, where that is such a robust map that is very difficult to replicate, I think, from an endocardial standpoint alone. And I think most electrophysiologists who've been in this game long enough would agree with that. And I know we always like to show our best maps or our most representative maps, but here's me on the left with that was my best attempt. I got some towards the left side, but not a lot towards the right side. But Kevin, that's why this is a hybrid procedure. Kevin still comes in, and with the tools available to him, makes the map no different than the one that you saw on the previous slide. So I can't tell you that every one of our maps look like my post-epicardial ablation that I did in that prior slide, but we have varied maps that over the years he trusts that we've gotten to a point where I'm going to do everything that I can do from a surgical standpoint, whether it's adhesions, whether it's anatomical constraints, that ultimately he's going to be able to touch this up, and maybe that's the beauty of this hybrid approach. So Convergent 2, and again, this is our nomenclature that we've put to these things, but Convergent 2 is really, as we were coming along, and everything we did AFib, everything we do AFib from a open concomitant standpoint, nobody would leave out addressing the left atrial appendage. That's a hallmark of the Cox maze for any type of maze procedure you do. So we started talking to ourselves in 2016, 17, how could we be leaving out the left atrial appendage? So now, in every one of our patients for many, many years now, it's posterior epicardial endocardial ablation, plus while we're in there thoracoscopically, taking down the ligament on a marshal, and then thoracoscopic left atrial appendage ligation. And I know people have seen these videos before, I just took a quick snippet, but I think it's, from a surgical standpoint, it's really important to not only have your VATS feed, but looking simultaneously with your TEE feed to make sure that you're absolutely as close to that base of the left atrial appendage. I always call it ligating slash excluding the left atrial appendage in my operative notes, because I really feel that what we do, looking at TEE, if the TEE, which is usually our cardiac anesthesiologist, say, you know what, there's a little pouch, I may not see it. From a VATS standpoint, we always manipulate that clamp to get as low as possible until we end up with the posterior mitral annulus up to the left superior pulmonary vein basically trying to be as flat a line as possible. So now in terms of this convergent three that we just presented at ISMICS just a few weeks ago, again, the one, we had additional energy sources. So we had always done the epicardial ablation and the endocardial ablation. Cryo came along. We had always used cryo. PFA has been basically what Kevin and other electrophysiologists have replaced in conjunction with the epicardial portion. We addressed stroke risk reduction with thoracoscopic ligating the left atrial appendage and addressing the ligament of marshal. And now additional thoracoscopic lines of ablation. In our series of patients that we looked at at four or five years, we had about 15 to 18% of these patients that were recurring not with atrial fibrillation but with actually perimitral flutter. And we felt, and we had multiple discussions about this, but we felt addressing that at the time of their index procedure, their convergent procedure, was probably important because we were trying to not have a bunch of patients end up back in an EP lab. So that's where we, that's why we chose the perimitral flutter line. And there were some other things. Once I was in there thoracoscopically with the EpiSense ST catheter, there's a bunch of different areas that I could get to. And I started this saying, nah, perimitral flutter, we're never going to be able to address that, Kevin. Maybe hybrid, we could try it. But I'm telling you, I can make a roof line that comes close to underneath the SVC. I'm never going to get underneath the SVC because we haven't dissected anything from a left thoracoscopic approach. And I said, this is going to be the greatest thing ever. It's a Sherman quotes success. And that was our map. We did have kind of what Kevin and I termed the hanging Chad. We left a line up along the roof and Kevin just said basically to the right here, Andy, this is of no benefit to me. I can do this in our electrophysiology lab without any difficulty. Stop with this trying to make a roof line. It's just not going to work out. And I know it's worked out in other centers. For us, that was not what we ultimately ended up achieving. But what we did do is take the, so convergent three, epi-endoablation, plus the LA ligation taking down the ligament of Marshall. And now we have a thoracoscopic, epi, and then Kevin completes this endoperimitral flutter line. So we realized that the clip was not enough of an anchor for Kevin to find endocardially that then come off of the clip and come down towards the anterior mitral annulus. We needed something else, a little bit more help. So we took our EpiSense ST catheter. You can see right at the base of the left atrial appendage. We're cognizant of where the circumflex artery is. There are patients where I've sent him pictures where he says, how come you didn't do it? And I show him the picture and he says, gotcha. See it right there. But this is basically what we do now in 2024 in every one of our convergent patients. And you'll see this gives you just a little bit of the open view of where this lesion is. I do it a lot of the times before the clip's on. Sometimes if it's difficult, I'll put the clip on and we can still get to that same spot. But this is something that Kevin can reliably see when he goes to then stage and map the patient. This was our concept is that we would have our posterior wall ablation that we endo-epi that we've done all along. There's our left atrial appendage and that blue line is me giving him a start along the epicardium and which is a transmural lesion, but a start that he can see on the endocardium that then takes him maybe 10, 15 minutes in the EP lab to create that anterior mitral line as opposed to what used to take him sometimes an hour or two to complete. This shows you our maps in confirmation of what we set out to do and what we were able to achieve. On the left and in the middle diagram, that yellow circle is my lesion that I've created along that epicardium with that one or a couple EpiSense ST burns just at the base of the appendage there. He latches onto. You see the circle down within that middle diagram. You see what Kevin needed to do to then connect where I started that lesion below that clip down to the mitral annulus. This was a picture from what we presented in ISMICS with our posterior wall isolation, the map from our basic regular convergent one to convergent two, a line that extends now an anterior mitral line all the way down to the mitral annulus that we've been able to do reproducibly now for probably the last two, three years. So in terms of our team, it's a lot of patience. It's a lot of collaboration over years and years. It's changed the paradigm of how we manage all aspects of atrial fibrillation within our health system, which is 16, 17 hospitals now, and it takes commitment. It takes commitment to understanding change, takes commitment to listening to each other. On the left here, I would love to tell you that Kevin and I are always hugging and having these wonderful times. This was a photo shoot that we just did for a foreshadowing of tomorrow, our Tampa Two open iteration maze that we've changed. It's given us the opportunity to give conferences, talks, lecture across the country with the likes of Dr. Cox and Dr. Gerdes, two of my outstanding mentors. But I'll tell you, with that comes also, you have to be ready to take criticism. This are just a couple texts that Kevin sent me. Hey, look at this hernia you created in this guy in the convergent. And on the right here was, I did my best with the convergent procedure, and I got the, seriously, were you even there? Did you actually do something to this patient? So it's a give and take. It's an important give and take because it's all ultimately for the betterment of our patient population who are afflicted with atrial fibrillation, and we know that all of us, we've seen lecture upon lecture of the numbers and what's happening with atrial fibrillation over the years and how significant a disease it is, and I think anything we can do as a team to try to address all aspects of this, we're all going to be better, and most importantly, our patients are going to benefit. Thanks so much.

atrial fibrillation

convergent procedure

thoracoscopic ablation

left atrial appendage

pulsed field ablation