{ "docId": "019dd923-622c-750b-8b98-08d95731b035", "docSlug": "4dea9707af58", "documentTitle": "AtriCure, Inc. (ATRC)", "authorId": "53_Kerrisdale_Capital", "authorName": "Kerrisdale Capital", "documentKindSlug": "research-note", "documentKindLabel": "Research note", "sourceTypeSlug": "short_seller", "sourceTypeLabel": "Short seller", "presentationDate": "2020-09-01 00:00:00", "orientation": "portrait", "aspectRatio": 0.77272725, "pageNumber": 26, "pageCount": 34, "prevPage": 25, "nextPage": 27, "slideType": "appendix_methodology", "function": "establish_context", "density": "dense", "nDataPoints": 0, "notes": "This slide provides background context on medical device innovation in cardiac ablation, citing specific clinical trials and studies.", "elementsJson": [ "paragraph", "footnote" ], "metadataConfidence": 0.95, "imagePath": null, "slideHref": "/slides/019dd923-622c-750b-8b98-08d95731b035/26", "deckHref": "/decks/019dd923-622c-750b-8b98-08d95731b035", "deckJsonHref": "/decks/019dd923-622c-750b-8b98-08d95731b035.json", "deckAnchorHref": "/decks/019dd923-622c-750b-8b98-08d95731b035#slide-26", "components": [ { "bbox": null, "kind": "callout", "text": "But all the innovation of the past decade seems marginal compared to Pulsed Field Ablation (PFA) and real time electrical mapping of the heart.", "attrs": null, "subkind": null, "toolName": "Visual emphasis", "toolSlug": "visual-emphasis", "confidence": null, "componentId": "019dd953-0396-73da-b906-5f28430a113f", "frameworkName": null, "frameworkSlug": null }, { "bbox": { "h": 0.28, "w": 0.72, "x": 0.14, "y": 0.18 }, "kind": "paragraph", "text": "Since the STAR AF II trial took place, several major technological and methodological innovations have advanced the efficacy, speed, and safety of catheter ablation procedures. Contact Force (CF) catheters, which were introduced commercially in 2014, allowed EPs to physically sense the catheter's contact with the cardiac tissue, as well as quantitatively monitor the parameters of that contact. Before that, EPs would use catheter tip temperature, weak tactile feedback, catheter motion and stability, and other indirect measures, to assess whether they were making durable lesions. While CF was initially less impactful than might be expected, as more studies were conducted, and various quantitative measures derived from the data that were newly accessible, clinicians learned to use CF to make more durable lesions, reducing the recurrence of arrhythmias. At the same time, the technology helped reduce the fluoroscopy time of a procedure (resulting in less radiation applied to the patient) and reduce the overall procedure time. CF has been instrumental in increasing both the efficacy and speed of catheter ablation.", "attrs": null, "subkind": "paragraph", "toolName": null, "toolSlug": null, "confidence": null, "componentId": "12b3567a-041c-4eff-a22d-707fdd2486e8", "frameworkName": null, "frameworkSlug": null }, { "bbox": { "h": 0.08, "w": 0.72, "x": 0.14, "y": 0.09 }, "kind": "paragraph", "text": "could result in death. Esophageal injury is particularly relevant to PW ablation via catheter because the esophagus runs adjacent to the left atrial posterior wall, and ablating the posterior wall endocardially could result in a fatal thermal injury to the esophagus without the proper precautions being taken by the EP.", "attrs": null, "subkind": "paragraph", "toolName": null, "toolSlug": null, "confidence": null, "componentId": "23d82c3c-c47d-4810-9272-34657e6f8775", "frameworkName": null, "frameworkSlug": null }, { "bbox": { "h": 0.13, "w": 0.72, "x": 0.14, "y": 0.46 }, "kind": "paragraph", "text": "From a methodological standpoint, High-Power, Short-Duration (HPSD) ablation has been another significant advance. As catheter ablation matured, academic clinicians theorized different power application strategies that could potentially increase the efficacy of catheter ablation. HPSD applied a higher dose of RF power to the cardiac tissue than had been previously used with RF catheters, but applied that power for shorter durations. The technique has been shown to result in fewer arrhythmia recurrences, while speeding up procedure time and reducing complication rates.", "attrs": null, "subkind": "paragraph", "toolName": null, "toolSlug": null, "confidence": null, "componentId": "bc4d3f23-21b9-4c02-8010-46ab07e5889c", "frameworkName": null, "frameworkSlug": null }, { "bbox": { "h": 0.09, "w": 0.72, "x": 0.14, "y": 0.6 }, "kind": "paragraph", "text": "Beyond CF catheters and the HPSD techniques, many smaller advances have improved the catheter ablation procedure. These include esophageal temperature probes, which help prevent injury to the esophagus while performing a PW ablation, and cryo-balloon catheters, which ablate tissue by freezing it, but also do so more rapidly and reliably in cases where large swaths of tissue require ablation. But all the innovation of the past decade seems marginal compared to Pulsed Field Ablation (PFA) and real time electrical mapping of the heart.", "attrs": null, "subkind": "paragraph", "toolName": null, "toolSlug": null, "confidence": null, "componentId": "ecbdb8df-ffa8-4b97-863f-d56d93179aa3", "frameworkName": null, "frameworkSlug": null }, { "bbox": { "h": 0.21, "w": 0.72, "x": 0.14, "y": 0.71 }, "kind": "source-note", "text": "23 For a survey of these advances, see Rottner, L, et al, Innovative tools for atrial fibrillation ablation\n24 For a review of the initial disappointing efficacy results of CF, see Ariyarathna, N, et al, Role of Contact Force Sensing in Catheter Ablation of Cardiac Arrhythmias. For a review of how Ablation Index (AI), a measure that can only be derived using a CF catheter, has been used to improve efficacy and speed of catheter ablation procedures, see Pranata, R, et al, Ablation-index guided versus conventional contact-force guided ablation in pulmonary vein isolation – Systematic review and meta-analysis\n25 A prospective trial of HPSD that resulted in higher efficacy rates is described in Yavin, HD, et al, Impact of High-Power Short-Duration Radiofrequency Ablation on Long-Term Lesion Durability for Atrial Fibrillation Ablation. Lower complication rates are discussed in Winkle, RA, et al, Low complication rates using high power (45–50 W) for short duration for atrial fibrillation ablations", "attrs": null, "subkind": null, "toolName": null, "toolSlug": null, "confidence": null, "componentId": "aeaf5c2f-34e7-4983-8460-e9d911760e05", "frameworkName": null, "frameworkSlug": null } ], "metrics": [], "tools": [], "frameworks": [], "arcBeats": [], "loops": [ { "to": 31, "from": 25, "name": "Cost Of Inaction", "slug": "27-cost-of-inaction", "bestFor": "Urgent budget requests, compliance, risk mitigation", "matchId": "3723b781-712f-4a89-8ac6-a6365db45803", "evidence": "The document presents a clear warning to investors about the risks of not acting", "position": 1, "objective": "To highlight the cost of inaction for investors who fail to recognize the threat of emerging technologies to AtriCure's business", "structure": "The Status Quo -> The Hidden Costs Accumulating -> The Future State of Inaction -> The Tipping Point", "confidence": 0.6, "description": "Quantify what happens if the audience does nothing" } ], "imagePathAlt": null, "thumbSrc": null, "thumbSrcAlt": null, "locked": true }