a couple of years ago, it was the last session, we're not the last session, and there were about three people in the front that stuck it out through the end, and he said, thank you for staying, and at the end they go, well, that's no problem, we're here to pick up the tables and take the chairs away. So it's my pleasure to welcome you to the San Diego Heart Rhythm 2025 46th Annual Meeting of the Heart Rhythm Society. If you've not done so already, I'm sure you have, download the mobile app. And this is how you can participate in the live Q&A during the sessions. Simply scan the QR code on the screen to access the session Q&As, and then log in with your HRS credentials. And then I'm supposed to also tell you that reproduction of the Heart Rhythm 2025 either by video or still photography is strictly prohibited. And with that, my co-chair Kamala. Good afternoon, and thank you for everyone sticking. You know, it's Sunday, and almost done, but I love it. So we have an exciting lineup of speakers here, and I'm Kamala Temerisa. I'm a EP physician based in Dallas, Texas, with Texas Cardiac Arrhythmia. And our first speaker is a wonderful friend, Dr. Abdul Salam, and she's from Vancouver, Washington, and she will start the talk. Hi, everyone. I want to start this talk by welcoming everyone to a new era of AFib ablation, where we've moved from the surgical suites to the sleek EP labs, where it's more comfortable, safer, and better for everyone, including us. We've worked so hard on technology, ablation, catheters, tools, but here's the thing. If our patients are waiting six months for seeing a consult and are not getting a phone call for their post-op care, are we really making a win in efficiency? And why does this matter? It matters because AFib is becoming a global burden. And it's expected that in 2030, in the US alone, 12.1 million patients are going to be having AFib. So that means that we're going to be seeing more and more patients in the clinic. And so as much as we want to focus on the success of the procedure, we also need to optimize the outpatient experience for the patients. We don't want them to feel like they're trapped in the cardiology version of the DMV. And so we have to think about this as a center of excellence for the patient, the experience, and their satisfaction. So through this talk, I'm going to talk about the bottlenecks that slow us down when it comes to AFib care. But more importantly, I'm going to talk about ways to eliminate those bottlenecks. From the referral systems to post-op care, we're going to go through how small changes can lead to big wins. Because optimizing AFib care is not just about the procedure, but it's about everything that comes before and after as well. So let's start with the front door, when patients show up when they refer to us. So a triage-based scheduling system can be a game changer. So instead of first come, first serve, we triage patients according to their urgency. So that patient who's been having a lot of palpitations, highly symptomatic, has been seen in the ED multiple times, that patient can be fast-tracked to see an electrophysiologist. But another patient who's had a flutter that was last in 2017 and is not really symptomatic, that patient can be seen by an APP first. And here's where technology meets common sense. So we have a lot of tools, like our EMR system. There are EMR alerts, there's smart scheduling, templates, integrated referral pathways. We really need to know about those resources and use them in an intentional way. In addition, a dedicated intake AFib coordinator can be very helpful, who can take the triage, look at patients, see who needs to be seen by an electrophysiologist and an APP. This translates into fewer phone calls, fewer drop balls, and more satisfaction for all of our patients. Now let's talk about one of the most underutilized superpowers of our EP clinics. It's our APPs. Those folks are brilliant, they're excellent, they're trained, they're sharp, and more than capable to run a lot of the aspects of our EP clinic. So they can initially see our patients, especially if they don't need to be seen urgently. They can talk about what to expect next, lifestyle modification, anticoagulation. And so that way we can free up all the consult spots for EPs to focus more on advanced decision making and performing ablations. So how do we stop handing patients a 15-page pamphlet that we know they're actually never going to read? Simply, we meet them where they are. With visuals, interactives, and on-demand education, the patients feel more satisfied and engaged. And so before they come to the clinic, we can create videos that are tailored to their disease process. They're short, they're engaging, and so patients come in well-informed. And let's be honest. A lot of patients have already Googled what AFib is, and so that way we're providing them with something that's more reliable. And so after that, we can take it up a notch in the clinic. So I have to admit that I have horrible AFib illustrations in clinic that I'd be embarrassed to put up there. So instead of using such images, we can bring the heart back to life like 3D animation videos. And when patients see the atria actually fibbing, it clicks in their mind. And what does that translate into? Patients understand disease process much better. They're more engaged. They know what questions to ask, which leads to better decision making and better outcomes and patient satisfaction. Now we come to the referral pathways. So we can't optimize and streamline AFib care if we do it from our EP towers alone. We need to build bridges and not silos with our referring process. And so let's start with the ED. The ED is a really important point of diagnosis of AFib because a lot of patients are newly diagnosed with AFib when they present to the ED. And so creating an ED to EP referral pathway is really important because it can turn a panicky ER visit into a smooth sailing clinic follow-up visit. And when patients know that they have that follow-up, it kind of relieves their anxiety and they feel better and they're more satisfied. But it's not just about the ER. Also our GI colleagues, primary care, sleep medicine, those folks see a lot of our risk factors and can really catch AFib early on. So if we provide them with the right tools, referral pathways, we can diagnose more and more AFib patients and get them to our clinic faster for better care. So we've done the ablation. Everyone's happy. We're clapping. Mapping system is happy. But it doesn't end here. It's the post-op care that really tests the efficiency of our clinic. And so there's a lot of key challenges in this aspect, follow-ups, lots of them. So patients are really, really anxious after their procedures. We see them show up to our clinic, especially in the blanking period where every PAC feels like a failure. Whenever their Apple Watch says something, they think they're panicking and they're showing up and they're calling. And so we really need to take care not only of the physical recovery of patients, but also on the emotional one. So how do we do that? So first off, risk stratification when we schedule follow-up visits. So not every patient needs to be seen as frequently. So our high-risk patients, those need to be followed very closely, multiple visits, make sure they're safe and that we're not missing anything that can be detrimental. But our lower-risk patients, we need to make sure that we're not creating, putting them in this limbo of constant clinic visits that they don't really need. In addition, telemedicine and video visits can answer a lot of their questions. Wearables, home monitoring, those are not pandemic leftovers. They're here to stay. And so instead of having our patient walk in for an EKG for every palpitation, they can check from home, from their home monitor, and then depending on their findings, we can have them come into our clinic. And I've been really surprised at how patients are actually really good at using this technology, especially our older folks. And so we really need to optimize using those resources. And then let's not underestimate the power of a good handout. So after the ablation, giving patients a good handout with clear instructions that answers most of the questions that may come up, for example, when to exercise, anticoagulation plan, what to do after, like what to expect after their ablation procedure, and what PACs mean, for example. That can avoid a lot of the phone calls and a lot of the patient anxiety that we see post-ablation. And in addition, this is not a solo act. We have a multidisciplinary team. We have APPs, RNs, pharmacists. We need to optimize everyone at their top of their licensure care. And so that means that our APPs can follow up with the less risky patients, and then that can free us up to see more complex patients in our clinic. And so it's important to note that we've got the most advanced technology in medicine. We can isolate triggers, avoid esophagus, we do PFA, 3D mapping, it's like a sci-fi in the lab. But if the outpatient side can't keep up, and if our patients are stuck in referral limbo, stressed out about their procedure, and lost to follow-up, are we really delivering the full promise of what AFib care should be? So the future of EP is rethinking how we deliver care from start to finish. So let's not get stuck on procedural success and lead the operational revolution. Our patients deserve nothing less, and we're more ready to rise to that need. Thank you. So our, I'm honored to introduce our next guest, colleague from Pacific Northwest is Dr. Mohair Ghandavalli. He's a high volume electrophysiologist up at Oval Lake Medical Center in Bellevue, Washington. And, do you mind passing that over? And he's here to talk about an efficient PFA workflow, zero floral considerations, tackling secondary arrhythmias, flutters, atrial tax, et cetera. Thanks. Thanks, Tarek. Good morning, everyone. So I think that was a really, really good presentation, a really high level approach to the AFib clinic. And now I'll take us back and get us into the weeds of procedural considerations. So my topic is about PFA workflows, specifically zero floral considerations and then an approach to secondary arrhythmias that pop up during these ablations. The first topic I'll touch on is just minimizing fluoroscopy and so I think one of the biggest things that we see with PFA is longer fluoroscopy times. So if you look at these trials here, there are four trials here comparing PFA to cryo, PFA to RF, what you'll notice is that with PFA cases, there's a consistent rise in terms of fluoroscopy. And a lot of that is due to the initial entrance into the field. We had a lot of single shot technologies that really came with the semblance that you needed to be reliant on fluoroscopy to achieve effective lesions. And the difference in fluoroscopy time is really more drastically pronounced when you compare PFA to RF. Because a lot of people have developed a low to no floral workflows with RF that work really, really well. And so that difference is really startling. You can see in the study all the way on the end over here, a single shot where they compare PFA to cryo. Those floral times are about the same. Again, higher than what we would see with RF. Here's some data from our own lab and kind of looking at our fluoro doses before and after PFA. And so we adopted PFA March of 2024. And what you can see is that our fluoro dose went up quite a bit from about 300 milligrays a case to around 500. So we're not immune to this, but what I would argue, and I hope to argue in this presentation, is that you can really keep fluoro at zero, both before PFA and after PFA, or as close to zero as you'd like. So I'm gonna go over some things that are specific to PFA, but also some things that are specific to just a fluoroless ablation. So I'll start with just the transeptal puncture. So for many of us, doing a transeptal puncture is very familiar. We can use x-ray to watch the sheath drop and identify the septum with a quick look at ice. But you can use ice for the entire transeptal puncture. So by putting some posterior flex on your ice catheter and a little rightward tilt, you're able to view the SVC. And then you can see your wire essentially advancing up the SVC. Once that's done, then you can advance your sheath over the wire, visualize all of that on ice. And then you're ready for your transeptal drop. So here you can see the sheath here making its way back and eventually dropping onto the septum. And as I just kind of counterclock a little bit, you'll see it here on the septum, and I can get to the lower part of the septum, which is where I'm trying to aim. And then once we're in a happy position, then we can advance our needle or RF wire and we're across. So all of that can be done really with minimal to no fluoroscopy. Then the question really is, is what do you do after that? And so for most of us who are used to doing cases, this is essentially where our ice ends. And especially if you're used to a low fluoroscopy approach with RF, this is really where you need ice. And then beyond that, you're reliant on your mapping system. You can create your three-dimensional map with your mapping catheter, and then you can start to ablate the veins. The tough part with a lot of these single-shot approaches to PFA is that they require a more detailed view of the left atrium, your left atrial target, specifically your pulmonary veins. And it's really hard to achieve that with right atrial views alone. So you can see here, this is a right atrial view of the left pulmonary veins, and there's a lot of dropout. And that's often because patients have this limbus here, which you can see is graphically represented. And that limbus just eats up a lot of our ultrasound signal. And as a result, you really don't get great images. The other part is when you look at the right pulmonary veins, not only do you get the dropout, they're often foreshortened, which makes it very, very difficult to see what you're doing when you're treating those veins. So for a mapping system, an ablation system that's point-by-point like Medtronic Afera, this is probably sufficient for all you need. But if you're looking at a single-shot technology like PulseSelect or AferaPulse, it's really hard to achieve a low-flora workflow using this alone. So a better approach is to use left atrial ice. So to advance your catheter into the left atrium, you basically bypass all of those limitations that right atrial ice provides. So you've essentially moved your catheter beyond the limbus, you avoid the dropout, you're in closer position to the pulmonary veins so you can see them in far greater detail. And so this is the same patient with veins viewed from the left. You can see that there's much better resolution just on a quick view. And then with the rights, again, you have better resolution of the rights, and I didn't put it in here, but if you just kind of play a little bit with your tilt and rotation, you're able to splay them open as you normally would when looking at the left pulmonary veins. So left atrial ice can be done in a number of ways. You can get a second transeptal puncture. I find it just easiest to use a buddy system. So here's an example of us going transeptal, and once the transeptal sheath is across, you can kind of dilate with your sheath. You pull your sheath back, you've got a wire there, and then as long as you just put a little anterior flexion on your catheter, you'll see that wire move up on ice, and that allows you to just slide your ice catheter across. And so there's the ice catheter sliding across. We've got our wire in place, which you can see in the left atrium, and then you can advance your PF sheath right over it. And once you've advanced your PF sheath right over it, like you can see right here, then you've got your sheath and your ice in the left atrium ready to go. So the biggest advantage of ice in the left atrium is that it does a really, really good job of making sure that you're in contact. And although pulse field ablation is really great at treating tissue, we know that tissue contact makes a difference in terms of efficacy, especially in the long run. So here's an example of a case of where we use the pentaspline catheter. And I would just focus on here and here. And as we treat the posterior wall, what you can see is with, you can see the catheter here on the mapping system, but you know based on ice that you're in excellent tissue contact. So before we deliver a pulse, we have confidence that we're actually touching the tissue and that we're in contact with the tissue and not just reliant on an approximation based on the ice, based on the map. And so that gives us confidence that all of our lesions are going to be effective and hopefully durable. Now mapping systems have tried to also overcome some of this to limit our reliance on ice. And so there are contact surrogates that many of the mapping systems use. So if you use OPAL for instance, this is sped up like 50 times, but they have proximity sensors. So as the catheter gets closer to the tissue, it turns white. And so you have a sense that your catheter is in contact with tissue as you see more and more of that white signal increase. If you're using Nsight, you have the opportunity to use their contact module. So essentially it creates a local impedance baseline when the catheter is not touching anything. And then as you're in contact, the splines will change from white to blue based on a pre-specified percentage change in impedance. And so that's another metric that you can use to essentially ensure that you're in contact and delivering good lesions without using or relying on fluoroscopy. The other thing I'll point out more as an efficiency thing, but not necessarily as something that's going to improve your durability is that with a lot of these systems, you don't necessarily have to create a huge map. So when we're used to doing RF, we're used to making these big left atrial maps, then creating our circles around the veins and doing what else we need to do. But when we're using single shot technologies or even something that's point by point like a FARA, you don't necessarily need to create that whole map before you actually start. So on the left, you've got a single shot so you can see the wire and you can hook up the wire to your mapping system and actually visualize it going up the vein. You know you're in the vein and that's enough for you to get started. And you've got your recording system to tell you what your signals look like and ice to allow you to assess for contact. So once you know that your catheter is here, it's sized appropriately for the veins using ice and you're in contact using ice, then it's very reasonable to just start treating. And as you go through your case, you'll be able to generate a full map. And similarly, here's a recent FARA case we did. We have the left veins all mapped. We have some voltage anteriorly. We didn't need to make a whole map of the left atrium before we started. We're able to just start delivering PFA. And over the course of the ablation, the remainder of the voltage and geometry will get filled in. So moving on to secondary arrhythmias. So it's inevitable when you're doing a PF case that you're gonna run into a secondary arrhythmia. And sometimes people go into typical flutter. Many times they'll go into an atypical flutter. And these come up when we're using RF and it's very easy for us to map and ablate with RF. But what do you do with PF? And one of the things that we're seeing with PF catheters is that they're more expensive than RF and they're adding financial stress to our system. And so if you have an atypical flutter where you have to pull up your PF catheter mapping catheter and then an RF catheter to treat it, that's a significant financial cost and it's also somewhat inefficient. If you actually look at ATs that develop in the course of an AF ablation, more often than not they're gonna be macro reentrant. And so these are studies where they've looked at folks getting PFA who've subsequently developed atrial flutters either during the procedure or after the procedure. And what they found was that the vast majority of them were macro reentrant. So just ignoring typical flutter, which comes up quite a bit, if you look at the macro reentrant atrial tachycardias that come up in this situation, they're usually coming from one of three spots, posterior wall, roof dependent, or mitral annular flutter. And so when you're dealing with PF cases and you see atrial flutter, you should have a high suspicion that it's going to be one of these three things. And what that really means from a mapping and treatment standpoint is that you can use the catheter you have in hand to create a map that doesn't necessarily have to be super, super detailed in order to define a macro reentrant tachycardia. Because we're not looking for very, very small areas of reentry or fractionation that could be driving these circuits. The other thing is we can go back to old school EP and use entrainment maneuvers, pacing from your CS, proximal distal, things like that to confirm the presence of mitral annular flutter. So here's an example of a mitral annular flutter that we did during an AF ablation. And this is a map that was taken with the pentaspline catheter. So it provides you more than enough detail, even though it doesn't have as many points as a high definition catheter, it gives you enough detail to actually identify the circuit and clearly delineate that it's going around the mitral valve. And then rather than pulling an RF catheter, you can use the pentaspline catheter to create a mitral line. And what you often see is that even before you complete the line, the lesion, the arrhythmia often terminates with the first or second lesion. So here's the catheter placed on the anterior wall. We deliver a lesion and the patient goes into sinus rhythm. And then one of the things that we always struggle with is durability of the mitral line. How well is it with RF? Are we able to really get block across the line? With a lot of these pulse field catheters, that's not an issue. So you can see that the line becomes pretty large, it's durable, you can easily show that you've got block across the line. Here's an example of a roof-dependent flutter. Again, the map was made with the pentaspline catheter. You're able to clearly show that there's some sort of reentry that's going over the roof and coming down the anterior wall. So just placing the catheter on the posterior wall to create kind of a roof line there. And with the first treatment, you're able to restore sinus rhythm. And then you can easily just extend the lesion set across the roof to complete your roof line. So in summary, I think pulse field ablation can be performed safely and effectively with really minimal to no fluoroscopy. When it comes to the single shot pulse field ablation tools rather than the point-by-point pulse field ablation tools, really left atrial ices invaluable for imaging and for reducing that fluoro exposure. When atrial flutters do occur in the setting of PFA and AFib, those macro-reentrant flutters really do predominate. And all of these arrhythmias can really be mapped and treated without the need for additional catheters or modalities. Thank you. Thank you for that incredibly very practical presentation. Appreciate that. And our third speaker could not be here due to last minute changes in their schedule and family issues. So we'll go on with our fourth speaker, effective integration of our APPs and AFib clinics by Elizabeth Starnes from Southern Medical Group. Thank you. Is it going? Flip the start. Okay, there it is. Sorry, technically challenged. So my disclosure actually is that I started working for Boston Scientific about five months ago, but that has no relevance to my talk today. I have history of being a nurse practitioner in EP for about seven years, predominantly out in Washington state and then in Florida. And while in Florida, I was able to start a pre-procedure clinic, which we found helped with a lot of the barriers and bottlenecks that we heard from Noshua. So I'll talk about that a little bit. So on the agenda, I'll briefly touch on what AFib is, what we know about AFib. We all have a lot of knowledge in that area, so I won't spend a lot of time there. Current guidelines, the pillars of AF management, which are really important, as we all know, and then I'll kind of jump into pre-procedure clinic and why APPs are so important and kind of piggyback on Noshua and the speakers today. So AFib, we know it's the most common sustained arrhythmia. It has increased morbidity and mortality rates globally. That increased burden of AFib is multifactorial. We know we have an aging population, rise in obesity, and an increase in detection. We have wearable technologies and all those ways of discovering AFib in people that we didn't before. AFib, of course, as we know, is associated with a one to two-fold risk of death and mortality, which is higher in women than men, as well as associated with a 2.4-fold increased risk of stroke. Touching on the pillars, this is kind of a holistic approach to AFib management. This is kind of where our APPs can really shine and be the superheroes that we know we are in clinic. The four A's, access to all aspects of care for all, that's super important. Focusing on stroke risk, making sure patients are on anticoagulation when appropriate, optimizing those modifiable risk factors, and of course, managing their symptoms. I'll touch a little bit on head-to-toe in the way of pre-procedure because that's kind of the focus of this talk and kind of streamlining that so that we make sure we take care of comorbidities in our patients. Of course, primary prevention would be nice, but I think most of us know that realistically once a patient comes to our EP clinics or our cardiology clinics, they've already entered into the secondary prevention realm of these guidelines. So secondary prevention, and this is gonna kind of focus more so on the pre-procedure aspect and what we can do with a pre-procedure clinic and using APPs to optimize comorbidities prior to a procedure that they have scheduled. There's a lot of talk. We've had a lot of great sessions on weight loss, physical activity when it comes to arrhythmia management and heart health in general. So we have a lot of benefits from medications, controlling diabetes, and overall, the metabolic improvements that can come from those things. There's not a lot of research on pre-procedure clinics, of course, and not a lot of research when it comes to cardiology pre-procedure clinics. So a lot of the data that you're gonna see in my talk is from anesthesia clinics or kind of more single-study clinics, as well as my colleague and I started a pre-procedure program in our clinic, so some of that data comes from the QI that we did as well. When it comes to physical activity, we noted that if someone can increase their physical activity six weeks prior to a procedure, the length of stay on average is less by two days. A lot of those studies came from orthopedic procedures, so they have a longer length of stay after in regards to cardiac, or in comparison to cardiac procedures, but when we talk about increasing physical activity, it's not couch to pickleball or couch to CrossFit. Really, the greatest impact in physical activity comes from just getting off the couch and moving. So with my patients, I typically educate them to just start once a day, just walk to the mailbox, do something small, and that actually shows a lot of improvement and decreases complications during and after a procedure. Tobacco cessation is always a fun one. We try really hard to get our patients to stop with tobacco, stop vaping. There's not a lot of studies on vaping, but they're coming out. But a lot of studies have found that if somebody can stop tobacco use six to eight weeks prior to a procedure, it actually reduces the overall complication rate from 52% down to 18. These are usually people that are undergoing general anesthesia, so there need to be more studies on moderate sedation and things like that that we often use in our cardiac procedures, but pretty significant reduction. Also, alcohol, nutrition, caffeine, these are big ones for our patients. I have a lot of patients that come in and say, well, how much can I drink? And old guidelines usually were okay with about eight drinks a week, not in one sitting, hopefully, but now newer guidelines are smaller amounts, more like three drinks a week. Abstinence about four weeks prior to the procedure definitely decreased the procedure complication rate from about 71% to 31%, but this was kind of a little bit of a delicate balance because we also don't wanna deal with alcohol withdrawal, which can greatly impact a patient's complications and recovery. Hypertension is also a big one. We know that the comorbidity of hypertension increases the mortality of a patient drastically. And so we do try and keep with the goal of keeping the blood pressure 130 over 80 or less, taking into account supine blood pressure. Typically, when patients see me in pre-procedure clinic, they've brought their log, we go over everything, and then I've got about three weeks until their procedure to try and optimize that so that they have the best chances of having no issues with blood pressure during their procedure. Sleep apnea is also a big one. We know that about 20% of adults have sleep apnea, which is grossly understated, I think. So early recognition with those screening tools is really important. I've had patients that I've monitored their sleep apnea, AFib burden with their devices, and they can go from 100% burden of AFib down to 20% just by treating sleep apnea. So I think that's a huge thing that, as APPs, we can really streamline in clinic and make sure that we do that pre-procedure. So jumping kind of into the meat of the talk, why consider a pre-procedure clinic, and why are advanced practice providers the best people for this? And in short, we have more time than doctors do. We are allotted more time in our clinic with patients to be able to educate them. And really, studies are starting to show that there's a huge benefit to pre-procedure clinics in all elective procedures. So day of surgery cancellation rates range from 2% to 24%, currently, depending on the facility, depending on the procedure, that's why that's such a wide range. And they found that 71% of those cancellations are actually kind of avoidable. They're related to incomplete surgical or medical evaluation prior, patient has acute illness, there's abnormal blood work the day of the procedure, or really, they just had no clue what their instructions were or where they went, and so they weren't able to follow them correctly. And then, of course, there are the insurance and financial barriers to these procedures as well. So utilizing the APPs in these pre-procedure clinics kinda helps increase access to care as well. As Nashua was saying, if we use APPs in pre-procedure clinics or as follow-ups, it really frees up the time for the physician to be able to see new patients and get them scheduled for procedures in a more timely manner, as well as it allows them to be more efficient with their lab flows. Studies also show a significant increase in the percentage of new visits that physicians can do. It went from about 49% new visits to 62% new visits when they utilized APPs in clinics, especially when it comes to procedures for new patients. Laboratory volumes also increased by about 10.75% with the utilization of APPs in clinic. So what do we actually do in these clinics? That's kind of an important thing to talk about. We get patients from all over the place. Oftentimes they're a secondary or a third opinion. They've had procedures before. They've come from all over the country, all over the world. And so really utilizing an APP in clinic allows them to gather that surgical and medical history and kinda combine it all. We can update the problem list, which is very efficient for insurance reimbursement, make sure that we're actually paying attention to all of the comorbidities. And then the biggest thing that I have found and the biggest benefit with my patients is just being able to educate them. We have the time to sit down and educate them. I'm a fairly bad artist as well, but I do try and draw them a representation of their heart and what they have going on and what the procedure is gonna look like. I think it's also important to note that the national reading level is actually about seventh to eighth grade. And CDC recommends that we print materials at a sixth grade reading level, but really our health materials are printed on a ninth grade reading level. So when we just see the patients in clinic and we give them all of these handouts and we say, go read this at home and you'll know everything you need to know, it's kind of not fair to them. So I think it's important for us to actually take the time to sit down and educate our patients in a way that we know that they'll understand what's actually going on with them and why we recommend what we recommend. Again, anticoagulation and medication management is huge. We have a coordinator that puts together a pre-procedure medication list. I often compare this with anesthesia's pre-procedure list and it's completely different. So you have a patient that has what anesthesia tells them to do and then what cardiology tells them to do and therein lies a lot of our anticoagulation crux. So I usually combine those things and have a really realistic conversation with the patient and I give them kind of the scary, if you take this the day of your procedure we're gonna have to cancel you. So we have a very clear conversation on anticoagulation and what that means pre-procedure and how exactly to take their medication so that that's not a barrier or a cancellation issue whenever they arrive. I also look at their most recent labs, diagnostics, make sure they have all the testing that they need done before. We do take a look at any recent infections, any recent antibiotic or steroid use because we do have patients that come in day of and they have an elevated white count and no one knew they were on steroids for something. I also in my pre-procedure clinic will do a full H&P. I'm often seeing the patients within two to three weeks of their procedure so it's within the 30 days required for an H&P. We go over all shared decision making tools and I get their consent if they're comfortable with it at that time. This allows us to kind of have a very holistic approach to their diagnosis and their procedure and what we're doing moving forward. It also allows them to coordinate their care. Oftentimes people come in and they say, well I don't have a ride, I this, I that. And that allows us to get social work involved so that we can actually help make sure that they have a smooth day on the day of procedure and they actually have a way of getting home if that's the case. I also talk to them about post-procedure expectations. I ask them if they need any notes for work, things along those lines because it's important that they're taken care of before, during, and after and that the provider and the lab and the clinic, everybody's on the same page. So in my pre-procedure clinic, we go over a lot of things. We prep a lot of things but the majority of it is education and reassurance for the patient. Like Nashua was saying, sometimes our procedures are scheduled three to six months out. They've seen the physician once. They get to my pre-procedure clinic and they say, I don't know why I need this and I feel great. So a lot of it is just re-educating the patient on what the goal is and make sure we're all on the same page. And again, the impacts and the benefits. If you do wanna do a QI at your clinics, it's great. We did one at ours. It was only about six weeks. It entailed about 100 patients but prior to pre-procedure clinic, we had about a 41% cancellation or reschedule rate. After clinic, we were able to reduce that by 50% and we had about 20% of people that were actually having to be canceled or rescheduled. Oftentimes, it would be administrative, insurance related or something in our lab was broken. So I think it is important to consider that. I did a pre-procedure clinic once a week and then the rest of the time, it was regular follow-ups but when you streamline the workflow, it reduces delays and cancellations and on average, patients who attended pre-procedure clinic had a 7% lower cancellation rate for these elective procedures. As I was saying earlier, we increase access to care and if nurse practitioners are being utilized to their full capacity, they're able to see follow-ups, they're able to see news that are uncomplicated and they're really able to streamline these pre-procedure patients so that the lab goes smoothly so that increases the clinic volume, increases the optimization of the physician's time so that they can get to these new patients that have been waiting a really long time for these procedures and then it allows for when that procedure day comes, it's a lot smoother and hopefully, it won't be canceled or rescheduled. Cost effectiveness, there needs to be a lot more studies on this but I think it's kind of, it speaks for itself. On average, with the studies that I've seen, the cost of unused lab or OR space is $1,400 to $3,600 per hour so that's not insignificant and overall, elective procedures, when we're not looking at orthopedic patients, the length of stay decreased by about 17 hours for the people that were able to be seen in pre-procedure clinic. So improved patient outcomes, improved patient satisfaction, most of my patients were extremely thankful for the education, they felt very confident going into their procedures and their anxiety was extremely less and we also had lower post-procedure complication rates because they were able to understand what they needed to do after the procedure before the procedure so those, please don't lift anything greater than 10 pounds rules really sunk in and they weren't just hearing it post-anesthesia and then forgetting all about it. It also allowed us to have respect for their time and their time off because a lot of patients do travel for these procedures, they do have to take time off from work and that's not an easy thing for a lot of people to do. So our final pulse check here, I hope you're still with me. Always put the patient first. AFib obviously is here to stay, it's growing in numbers and so we need to stay with it and utilize your established and available resources, APPs being those superheroes in the clinic. So thank you for letting me conduct this session, I hope it sparked some action potentials. Thank you. That was a very wonderful presentation, thank you so much. We'll just start with the first question. What is your typical follow-up schedule for a patient after AFib ablation or after the same day discharge? Elizabeth, you wanna take that? Follow-up after same day discharge? So I think, is this on? I think with PFA that's changed quite a bit. We typically, you know, after an AFib ablation we would have them stay overnight one night but with PFA we've actually been sending people home same day. We typically have a nurse see the patient within a week to check on the groins and then if it's an AFib ablation we see them in follow-up about six weeks post-ablation and then three months post-ablation if there is any sort of recurrence. In AFlutter we see them about two months post-ablation. Now in my pre-procedure clinic I do talk extensively about the blanking period and I am very realistic with my patients and I say, you know, this isn't a cure. This is to decrease the burden of the arrhythmia on your heart so that you have a better quality of life and that hopefully you get, you know, some of your life back and so I kind of preface it that way but typically we see the patients in follow-up clinic about one week by nurse, six weeks to two months by APP. I just had the same question for you, Meher. Do you follow-up? When do you see your post-ablation patients, same day discharge you can use them? Sure, thanks. Yeah, it sounds pretty similar. So we send everyone home the same day and then they usually follow-up in clinic with a nurse, sometimes an APP, at a week or so depending on the acuity of the patient and then if they're doing well we actually forego the six weeks and we'll just kind of see them at three months. Okay. Great. Wonderful. So we, second question we have here is do you use videos or models in clinic to explain anti-ablation and what about a video visit? I just, I'm going to actually chime in here a little bit. There's a video that came out from the New England Journal of Medicine, it's like a 13 minute video and I put that on my app to visit somewhere, it kind of goes over everything that was said and I believe there's a ACC cardio source, is it cardio, I can't remember, it's a heart model, it's got the whole ablation, flutter, everything, it's a very helpful tool and during a video visit I set up a PowerPoint, in fact my video visits are probably the most efficient visit, I can actually spend a full 15, 30 minutes, whatever, with a patient online. But just any thoughts, Nashwa, you had mentioned it in your talk. So for our clinic we're changing things a little bit because we realized that what we're doing is not efficient, so we weren't doing any video visits for first time patients, for that reason we weren't using the visuals, so we're actually working on a plan of how to optimize the AFib clinic because we realized that that just doesn't work, you're taking so much time during the clinic, so I think implementing that video before the patient comes in, because when I see a referral from general cardiology or from a patient who's been talked to about AFib before, it's very different than patients just walking in, they don't know anything about what you're talking about. I had a couple of patients break out in tears and cry because they're so overwhelmed, so for us it's just, we're still working on things. Any other thoughts? Do you want to add anything to either of you for the video material or infographics? I think video visits are great in general, and I agree with you, Tariq, it really just kind of streamlines the discussion and it really allows you to kind of focus on the matter at hand, and I think the nice thing for patients is that they're doing this from the comfort of their own home, so they're in a really comfortable setting that doesn't feel stressful to them, and then for patients near or far, I think it just has been really working well for us. I think the only caveat I would add to that is that we're still in this unknown gray zone with Medicare and reimbursement, and they keep kind of pushing the envelope, and so now we've gotten this reprieve until October, so I'm hopeful that someone comes to their senses and makes this an indefinite thing, because it's clearly a benefit to our patients. Can I counter this thought with something, though? For video visits for first-time clinic visits, sometimes I feel, though, they take away from, like for a first time, not the follow-ups, it takes away from, especially if the patient is in proximity, they are not, like, remote and they can come in, I feel it takes away that, like, connection with the physician who's going to do the ablation, so that's just a counter thought about the video visits for first-time patients. So there are only 2,000 EPs in the United States, and there's a large chunk of the country that doesn't have access to specialty care. I'm fortunate to have some access to do some clinic down in Oregon, and I'm surprised at how well our elderly patients are able to navigate the video world, so. All wonderful points, you know, pros and cons of those video visits, and yeah, it's still something we are, with the reimbursement changes, we shall see. Question for Elizabeth, you know, do you ever have any dissatisfaction from patient's angle if the referral is for an EP physician, and if you, as a nurse practitioner, you're seeing them, and if you do see that, how do you overcome? What kind of tips can you give us? So I'll say the biggest dissatisfaction that I hear from patients as the nurse practitioner is I just didn't have enough time with the physician. You know, they told me one thing, they recommended a procedure, and I don't see them again. And I think that is very frustrating for patients, but it's kind of something that is out of you guys' control for a lot of reasons, insurance reimbursement, time allotment in clinic, things like that, and so I just reassure my patients that it is a collaborative effort with the entire team, and that we are an extension, we are basically a limb of that physician, and we are in close communication with them, we talk to them daily, and they are very involved in the care of that patient, despite seeing my face instead of their face. I also reassure them that, you know, they know the plan, and they agree with the plan, and most patients are fine with that. Excellent. You know, I can vouch for that. You know, we have a nurse practitioner team, physician assistants, and nurse practitioners, and with the physicians, most patients are pretty open if we explain that it's a collaboration, if a nurse practitioner or a physician assistant is seeing you, it doesn't mean the procedure is not done by the EP physician that you were referred to, so I think you really hit it on the nail, collaboration and open communication, just to alleviate their anxiety. I found that when they feel educated and they feel like a huge part of their own care, then most of the time their anxiety dissipates completely. So there's a question about the average time of patient interaction during pre-procedure and post-procedure follow-ups, and do you find it sufficient enough? I think you kind of touched on that. I just wanted to add, we had a speaker that did not come in, and I was actually interested in hearing him speak about clinical space, manpower, pre- and intra-procedural considerations, and I know your lab looks at this, but one of the hats I wear, I was going to business school right before the pandemic, and we had a project management class, and I picked cath lab, EP lab, optimization, and my dyad partner also was going to business school at the same time, and I was surprised. There's this concept of floating bottlenecks, so essentially what we did is we had a run-in, taking a look at patients, wheels in, wheels out time, and looking at the entire process from check-in to check-out, and you always think it's a cleaning person or something like that, but it turns out it's, if you really sit down and have any of your project managers or yourself, or actually some of the companies have folks that can come in and they're bean counters, essentially watch you around, they'll note inefficiencies in bringing people in and out. It can be communication handoffs, it could be, you know, there's taking lunch and strategies for switching how people take lunch, but what happens is once you identify that one bottleneck, you'll end up with another bottleneck, and then another bottleneck, and over time, we were, on our own, we were able to cut our wheels in, wheels out time by 20%. Recently what we've been doing is on the window, we'll write down wheels in, wheels out time, and it has the time in there. This way we engage the anesthesiologists, because all of a sudden they have this competitive nature, and they want to get this thing done in less than 30 minutes, so I don't know, do you all have any input on that particular aspect? I mean, you know, yes, in a work lab space, because, you know, we have a very good model, is a few things, having designated anesthesia team is very important. That used to be the bottleneck before, you know, we didn't have anesthesia designated team, but the charge nurse, the nurse leader for one lab, she pretty much, he or she, runs the show for the day, so it's one leader per lab, and that leader communicates with anesthesiologists the night before and says, these are the cases, this is the physician, because each physician has a workflow in their own pet peeve, so, you know, knowing that, and then having the patients, the second thing is having the patients come in two hours before the schedule, depending upon how far they live, you know, two to three hours, depending upon your lab. That way, when the case is ending, and the helper for the anesthesiologist is taking the first patient off the table, the anesthesiologist already sees the next patient, so the turnaround time cuts down very short, and the post-operative team is pretty much there, again, in part of the dialogue with anesthesia, they do their briefing in the morning, this is the physician, these are the number of cases, and this patient is going to go home in two hours, three hours, so there's a plan laid out on the board, so that way, less talking and more just efficient workflows. Any other thoughts down there? I know Overlake's a pretty high-volume lab, how do you manage that, who's your, what's been your strategy? Yeah, I mean, I think we, a large part of our success is just having the right people in place, we're really lucky to have a great team on all levels who are working together and have a singular goal, which is to deliver good patient care, but also be timely about it, and I think we kind of hit on, you've hit on a lot of the things that we try to do, I think there are some things that are hard to, hard to overcome, such as where do you recover your patients, if you have to go two floors up and three buildings over for your PACU, you're never going to, you're never going to get any traction there in terms of what you can overcome, but we did something very similar to what you did in terms of tracking our patient in, patient out time, getting a sense of what our actual turnover time was from the time that the patient left the room to the next patient coming in, and then that's really helped us kind of identify what we can do in terms of improvements inside the room and then outside of the room, and then we did make a logistical improvement, so we were sending our patients up to PACU, which was a floor away and down the hall, and then we worked with our recovery team and hired some nurses with critical care training to actually recover the patients in, in our, in our regular recovery unit, which is just next door to the EP lab, so that's really helped us with our recoveries as well. You want to add anything? Yeah. I think the part of the ICU patients and the critical care is really critical because we have that issue where they can't recover in PACU, you have to take them up to the ICU, and so that delays care, and I think the communication part, the communication issue between, creates a lot of delays, especially when people are not on the same page. We also had the same issue with anesthesia, but once we had a dedicated anesthesia team, that kind of changed things, but I think the whole thing is also that everyone should have the same incentive for the same goal, especially when it comes to, like, if you want to get the cases done because there's an add-on and the lab works at a certain, up to a certain time, so we, everyone needs to be incentivized in a way that they're all working towards the same goal and that we don't have different, you know, incentives, so. There's a question, how many patients do you see pre- and post-procedure for follow-ups in a clinic day? I think one of the APPs might want to know. So pre-procedure clinic, I had 20-minute slots, and I was trying very hard to see patients every 20 minutes, but I ran into a clinic bottleneck as in staffing issues, and it was really hard to get ECGs because part of my requirement for a pre-procedure clinic was to get an updated ECG. So I extended my appointment times to 30 minutes, and I also found that a lot of patients had a lot more questions than I had thought was originally going to be the plan, so to give myself enough time with the patient and to make sure that all the questions were answered and that I got the blood work and all the testing done that I needed, I would see patients every 30 minutes. I started at 8 in the morning, and I went until 3.30 in the afternoon, and so I could see anywhere from 10 to 14 patients in one day. And I did that one day a week, and then I was in the hospital the other days, and speaking on streamlining the procedure days, you know, I would look at kidney trends and lab trends and all that stuff because that can be a delay for cases. You know, their lab work comes back funny, their consents aren't done, and so pre-procedure, I had about a 30-minute slot. Post-procedure, if it was someone that I felt would not be complicated, it would be a 20-minute slot, and I tried to see 10 to 14 patients a day. Well, so we have a question about chatbots. If any of us, or we don't, but any thoughts on using chatbots for patients to interact with? Like the patient messages? Chatbots. Just a chatbot. Chatbots. For patients. Alexa. So... And just clarifying, it's the patient messages that come through Epic, right? Interactive. So, I mean, it can be very helpful with a certain kind of patient, but with a lot of patients it's a problem because we get so many of them, they need to be trashed first before they come to me. Some patients think that that message comes directly to me, or that I have a phone, and they get very frustrated when you don't answer their messages, or some patients just want to send you messages about every single thing that they do, so I've had a lot of issues with that. When it's with the right patient, it's really efficient because they send a message, I answer, we're done, we don't have to wait for the phone call. But I think with a lot of patients and the expectations, I think it's difficult, and I think we can use it efficiently if the patients have the right expectations, which I don't think they really have. Excellent. So, we're at the end of our session. Thank you very much. Thank you to our panelists here, and thank you all for toughing it out for the last day at HRS. I believe there's one more session, and then I hope you enjoy the rest of the day in beautiful San Diego.

San Diego Heart Rhythm 2025

atrial fibrillation

electrical pulse field ablation

patient care

Advanced Practice Providers

home monitoring

zero-fluoro techniques

pre-procedure clinics

video visits

telemedicine