Hi, everybody. Welcome to today's webinar. We're really excited to bring this to you today. But at the same time, we want to make sure that everybody can benefit from this. And so while we're here and ready to get started, what we'd like to do is just give another minute or two for others that are currently logging on to the system. And so we will really officially kick off in about a minute, minute and a half. So thanks for being here. And thanks for being on time and we'll wait for a couple others who are making their way in. Okay, everybody, thank you so much while we waited for a few more just to join us. My name is Joe Sasson, I'm the executive vice president of MedAxium Ventures. And today we're bringing you a webinar on achieving the quadruple aim with post-TAVR MCOT monitoring, a multidisciplinary roundtable with University of Maryland Medical Center. And so with us today is Dr. Amara from University of Maryland, Dr. Chahal from University of Maryland, and Rachel McCumbers, who used to be at University of Maryland and is now a clinical application specialist with Phillips Ambulatory Monitoring and Diagnostics. And so all three are part of the story that we're looking to tell today. As this is a new system for MedAxium, I want to make sure that it's really simple and easy to use. We've all been on Zoom for a long time now. But if you would like to chat, if you need to send a message directly to one of the hosts or one of the support team on the line today, you can do that. You also can make comments that everybody can see and have some discussion around the content being presented today. So feel free to use that. If you have questions for the presenters, please use the Q&A button instead. And then we will filter those in either during the presentation as appropriate or hold some to the end. But I'd prefer if anybody that has questions brings those to the table as they have them, because I'd like to make sure that they're answered in a short order. Today's discussion is really going to be primarily based on Q&A. What I'd like to do, although I gave a very split-second introduction, is make sure that all three of our presenters get to share a little bit more about themselves so you can contextualize the experience they bring to the table as we tell this story today. So Dr. Amara, I'd like to start with you to introduce yourself and your role at University of Maryland. Sure. So I'm Richard Amara. I'm a cardiac electrophysiologist here at University of Maryland. I've been at Maryland for a while now, a little over five years total. And right now, you know, I'm very involved in helping with rhythm management post-TAVR and also helping with interpretation of the MCOTs, you know, after patients are discharged and, you know, if needed, EP studies and pacemakers on these patients. Thank you, Dr. Amara. Appreciate it. Dr. Chahal? Yeah, my name is Diljan Chahal. I'm an interventional cardiologist. I serve as the director of the cath lab and interventional cardiology at the University of Maryland. And my role primarily, you know, is complex PCI, chronic total occlusions, and structural heart disease, including TAVR. So we work closely with Dr. Amara and Rachel, who you guys will meet as well. Thank you for that. Really appreciate it. And Rachel, how about you? Hi, everybody. So I'm Rachel McCumbers. I am a nurse practitioner. I worked at University of Maryland from 2009 up until March of this year. I was a nurse practitioner, obviously, and structural program manager specifically for TAVR. And then, yeah, I started with Philips, and now I'm a clinical application specialist working for Philips. Excellent. Well, thanks to all three of you for being here. This is a real exciting story for us to tell, and appreciate you taking the time to do that for us. What I'd like to do is just give a little bit more context of your organization. So Dr. Chahal, if you could describe maybe the practice, the patients you serve, the services you guys have at University of Maryland, you know, number of sites, number of patients, you know, service area, that would really help us to kind of get a feel for your institution. Sure. Thanks, Joe. Yeah, so University of Maryland is actually pretty unique. We're an 11-hospital system, and it's kind of set up as a hub-and-spoke model. So a bunch of the outlying hospitals, we get a lot of the referrals, which drives a large majority of our volume. We have a large shock trauma center here, which is kind of world-renowned, but definitely adds to the case mix that we see here. As regards to our service lines, you know, we have a big VAD, heart transplant program, probably one of the busiest cardiac surgery centers in the state of Maryland. And with regard to TAVR, you know, volume-wise, we're roughly doing, I'd say, about 330 to 350 TAVRs now per year, and it's continually growing. We have a CTO complex PCI program that is pretty robust as well. So, you know, the patients we serve is a mix of inner-city patients and patients, you know, from the suburbs of Maryland throughout the entire state. Our cases that we do regarding TAVR, which I think we'll probably end up discussing as well, is a good mix of the balloon-expandable and self-expanding valves with maybe slightly more balloon-expandable valves. And yeah, I think those are pretty much the big key points. We can touch on other things if you guys have questions about it. No, that's perfect. Thanks so much for that context. Let's dive in. So, Rachel, I'd like to start with you. I mean, and you were a big part of the white paper that we did with University of Maryland, you know, here at MedAxiom as well. And we see, obviously, TAVR volumes are rising across the country, and we're also, most programs are seeking to shorten the length of stay, right? And so post-TAVR monitoring, it's receiving, you know, heightened attention these days, you know, so that we can detect heart block and new onset AFib within the first 30 days after TAVR. So what I'm interested in is really, were those types of things the driving factors that created this program, or what other factors led you to create this program for post-TAVR monitoring at University of Maryland? So the main driving factor for starting our program was, unfortunately, an adverse event that happened with one of our patients. There was a patient who was discharged after TAVR, an uncomplicated TAVR, and on day 16, he had a bradyarrhythmia, which advanced. We did get a lot of information of what happened, but it does look like it was, you know, delayed heart block. And that patient, unfortunately, passed away, not at our facility, at an outside facility. And I do remember very vividly, you know, how we felt about that. It was very devastating. We really took a lot of time and care and concern about our patients, even after they left the doors of our hospital, you know? And so I went on a quest very quickly to figure out what I could do to keep this from happening to anyone else. And initially, it was funny. I still laugh about this for some reason, but I was looking for an external wearable pacemaker. I thought that was, I don't know if I thought that existed or I wanted it to, but nonetheless, it doesn't exist. And if anybody comes up with it, it might work. But anyway, so anyway, we found the MCOT, and we found Philips, the AE, the salesperson that worked at University of Maryland was somebody I hadn't met before. Her name is Lauren Swope, and she's amazing. So we worked very closely together for a good while to put together a program. You know, it wasn't enough for us to just put heart monitors on patients. It was really constructed as a program. And we had to take so many factors into consideration. We needed it to be easy for our staff. We needed it to be easy for us, the core TAVR team. And when I say easy, it just had to work. You know, being able to get the notifications, being able to get the monitors on the patient, but ultimately had to be patient-centered and focused. And we launched our program March 2nd of 2020, which you know what happened right after that. We went into complete like COVID mode, for lack of better words. We felt extremely thankful and fortunate that we had launched this program, because not only did it serve to notify of any arrhythmias, but we were also using the monitor in a different way, because we went virtual. You know, our patients are elderly. Our patients had comorbidities. They didn't necessarily want to come in during that time to an emergency room for an evaluation of a symptom, or they didn't necessarily want to come to a doctor's office even, or urgent care. And so we just had an extra layer of monitoring and protection when we were trying to decipher anything that was going on post-TAVR. So again, that's why we launched our program. Of course, there's so much more detail, but that was the reason. Well, I appreciate that. That's a humbling story and a great motivator for change. So I mean, thank goodness that you're as passionate as you are to put that into place. From the physician perspective, I'm curious about how, you know, the use of MCOT and being able to capture every beat and, you know, near real-time, how has that helped you to kind of treat these patients now with these arrhythmias? And I'll start with you, Dr. Chahal. Yeah, thanks, Joe. You know, I think the biggest thing with the real-time or near real-time notification is that, you know, we're able to act on these alerts quickly, and especially the most devastating consequence of a complete heart block. And I think that's really made a big impact. You know, I can count at least, I think, 15 patients where we've had some sort of heart block that we've noticed, which has made a real impact in getting those patients in, getting them a permanent pacemaker over the course of all these years. And, you know, I think one of the biggest things that we've also noticed is, you know, it actually has decreased the use of, you know, sending the patients through the ER or having them, you know, present as some sort of trauma from a head injury, from a syncope. I think we're able to act on some of these alerts quickly enough to prevent some of those adverse consequences and get them in, you know, for immediate treatment. Thank you. Yeah, that makes perfect sense. Dr. Amaro, would you want to add anything to that in terms of your practice? Yeah, so I would also agree that it certainly helped quite a bit. You know, we know that high-grade heart block happens to a significant amount of people post-TAVR, and, you know, we do our best to evaluate people who have conduction disturbances, you know, immediately post-TAVR, you know, whether that be monitoring EKGs while they're in the hospital or even taking them for EP studies, but, you know, we're not always correct with our assessment of whether or not people will need pacemakers immediately. And so it's really nice to have these MCOTs monitoring for a month because we know that that is a, you know, a large bulk of the pacemakers that go in post-TAVR happen within that month, and it's within that month that we detect a lot of heart block. So it's nice to have that monitoring ability during this vulnerable period. And just to echo what, you know, Dr. Chawla was saying, you know, I think that we can act very quickly on it, too, just because we have this real-time monitoring analysis. Got it. Well, thank you for that. I think both of your perspectives there are critical. Rachel, you told us about the impetus for creating the program. I'm hoping you can share a little more detail on kind of how you built that out and how you operationalized that, and what did that look like in terms of coming to fruition? How did that happen? You know, not the why, but the how. So thankfully, as a program manager, I had a lot of connections with the different departments that TAVR patients touch. You know, there's the outpatient, and then, of course, the operating room, and then the inpatient. And so early on, I got key stakeholders together. I went into the hospital. I spoke with nurse managers. I spoke with nurses, charge nurses. I talked to them about my proposal or possibly some of my ideas. But one of the best things I ever did was before making any decisions at all, I spoke to the experts, the people who were going to be involved in the placement of these monitors. And they, you know, they would tell me, yeah, that would work, or this might be the best person for that, or, you know, we knew what we wanted to do. We knew we needed to put these monitors on the patients before they left the hospital. We didn't really know if that was being done anywhere else, so it was a lot of discovery. And then when you go to your staff and you talk to them about your proposal, then you get buy-in. You know, when I'm able to sit down with the nurses, with the nurse managers, and say, this is why we're doing this. There was a person who passed away. This is a real problem. Like, help me fix it. Then all of a sudden, you're a team, and you're problem-solving together. One of the best things we also did when we would have a save or something amazing, you know, that we could intervene on a patient, I would call the nurse that put the monitor on that patient, because that's how we had it set up at university, is that the discharging nurse did place the monitor. But I would let him or her know, like, you didn't even know it, but you did something amazing, you know, and let them know that success story. Again, it's really just about being a team. And so I always had support from the Core Tower team. You know, our team was just always patient-focused and doing what was best for the patients. And so we thought through every step of the way, and we designed the program. Now, I'm not going to say that it was perfect. There were things that we could improve on. You know, I mean, there was a time where we had to go back to the notification criteria and readjust it, or, you know, just talk through how we, you know, where we held the inventory. Just think, you know, the details. But overall, it was extremely successful because we took the time to really plan. All right, thank you. And it sounds like that's probably a lot of team effort and some challenges to overcome and a lot of people to align. But all of that's done, you know, for the patients. And so one of the things I typically want to ask about is, you know, give me a story. Tell me where the use of these monitors and the use of this process and program post-TAVR has really made a difference in the life of a patient. Dr. Amar, I'd love if you could take a first stab at answering that, if you have something in mind or a patient that comes to mind for you where it's really made an impact and potentially saved their life. Yeah, certainly. I think, you know, there's two relatively recent instances that come to mind on some specific patients. You know, I was mentioning earlier about conducting EP studies on these patients. So, you know, generally speaking, if they have a new left bundle branch block after TAVR, we would do an EP study to try to help evaluate the risk of, you know, needing permanent pacing. And sometimes we feel that risk is low, but we can definitely be wrong. You know, there's a specific instance I remember of a lady who had this new left bundle branch block. We did an EP study and felt she was at low risk, discharged her. And then, you know, several days post-discharge, we saw a complete heart block, you know, on her monitor and we were able to bring her in for an urgent pacemaker. And another sort of similar instance was a patient who just transiently had a left bundle branch block after the TAVR was placed, but that resolved. And generally speaking, when conduction abnormalities go back to their baseline and resolve, we feel they're low risk for progression to heart block, but that's not always the case. And, you know, in this patient, he had very symptomatic episodes of complete heart block that we immediately caught on the monitor. And again, we were able to bring him into the ER and then urgently put in a pacemaker for him. So, you know, those are the two specific instances that come to mind. And those were both from relatively recently. Thank you for sharing that. Those are the good days, right? That's a rewarding day in the business. Dr. Chahal, do you have a story as well or some impactful moment to share? Yeah, definitely, Joe. You know, I think there are definitely a handful of these cases, but there was one that kind of, you know, I remember vividly. It was a patient that had transient asystole, you know, during valve deployment that resolved narrow QRS, conducting normally in a sinus rhythm afterwards, was ultimately discharged home. And then we got, you know, the biotel alert for complete heart block. Attempted to reach the patient multiple times with no answer. Patient lived independently by herself and family wasn't able to reach her as well. And so actually, with the help of Rachel, and Rachel, I don't know if this is one of the stories you were going to tell. Contact the police department who was able to attempt to contact the patient, entered her home and found her, you know, laying on the ground, basically in a bradycardic arrest with a very faint pulse and resuscitated her, got her to the hospital. And this was all real time. I don't remember the exact time, Rachel, when it was. It was on a Sunday. We got the patient on a Sunday, that's right. And got the patient to the hospital, had a permanent pacemaker placed, and she actually, you know, did survive that episode. Yeah, go ahead, Rachel, if you wanted to add to that story. Yeah, that was definitely like, I've been out of the ICU for a number of years, but I will say that was a heart pounder that day. Yeah, so when we called 911, and again, you know, every program is set up different, your protocol, how you handle not being able to get in touch with a patient, you know, it's not that I recommend anything, but we did decide that if we were unable to get in touch with a patient that we would call 911, which we did. And I do remember talking to the sheriff of her county where she lived, because she lived way out remote Maryland. And, you know, he said, you were right. I did need to, I needed to go in. I said, yeah, I told you, when you get there, go in. So we were just very, very happy about that. I did have one, I had one more story. I got a really serious alert about a very, very long pause and call the patient. And he answered the phone. And so I was, I asked him, you know, initially, how are you feeling? He goes, you know, he's just like, I don't think I ate enough today. And I'm pretty sure I didn't drink enough water because I am really dizzy. I said, well, that's why I'm calling you. So of course, you know, I made the recommendation for him to go to the ER. But I tell that story because, you know, if he hadn't been wearing a monitor, he would have thought he was dehydrated. Like that's, and again, that's what he thought. I mean, that's how he felt. So the monitor was able to give us, you know, that real time view of really what was going on with that patient. So I was very thankful for it. And it worked out well for him. That's awesome. Thank you guys for sharing that. I think it's just reaffirming of why we do what we do and that all of this touches patients. And so I have a couple of questions that have come in. I'm going to ask them, but if they are not a fit or you're not comfortable answering them, that's okay. And we will follow up later. But the first question is, have you had difficulty with insurance approving the monitors? Because we find in our practice that some insurance will only approve MCOT if they've had a stroke. So I don't know if you can speak to that insurance process or not, but any of you, three of you that can feel free, if not, we'll push. So I can speak to it. I'll generally speak to it. If there's any questions or concerns about insurance reimbursement, we do have the ability to supply a list of our payers. And we can also, one thing that was really important to us, not only insurance, but out of pocket expenses. So of course we're dealing with an older population who may be very much on a limited income. And so we couldn't, we could not deal with the thought of putting a monitor on a patient and then them getting an astronomical bill. And so in the state of Maryland, and we can do this for any region, since I do now work for Phillips, we can give you a breakdown of average out of pocket costs so much so that we can say how much of that region has zero out of pocket. And so I'm pretty confident in saying that we have answers for that. Okay. Okay. I will push forward. The second question that came in is related. And so it may go to you as well, Rachel. And that is how do you contain the cost of adding MCOT to every TAVR case? TAVR reimbursement is already low in our state in proportion to the existing implant costs, of course, of the valve. And so how do you, how do you build the cost of MCOT in, which I would assume would be separately billable, but why don't you answer that? The short answer is it's zero cost to the hospital. Um, the, the charge for an MCOT monitor is an outpatient charge and it's charged to the patient. And so it does not cost the hospital. That's the beauty of, that's the beauty of what we've seen is that obviously every, every TAVR program, we know that TAVR is expensive. And so the only way to make money for lack of better words is to save money. And so you obviously don't want to add another cost. So the MCOT monitoring program would cost nothing to the hospital. Um, and so by utilizing it, saving lives, hopefully decreasing readmissions, um, you know, all of the benefit is that much more of a benefit because it doesn't cost anything. There's no monies exchanged between the hospital and the provider of the MCOT. Yeah. Thank you for that. And so I think that's a really clear explanation of how that process works. I also want to thank folks for chiming in and asking questions. And so we know that the Q and A button is working and feel free to continue to use that. Um, pushing forward here, you know, according to, you know, the, the recent ACC guidelines on TAVR, um, we see complete heart block requiring a permanent pacemaker in about 15% of patients, um, within 30 days of TAVR. And so I'm curious, are you seeing those same rates? And are you seeing that, you know, around that 15% is that high? Is that low for your institution? Um, Dr. Chahal, could you maybe provide a little bit of context around that? Yeah. You know, I think that number is pretty accurate. I think at least originally when we started, uh, the rates were about 15%. And there've been different techniques we've done to help kind of modify, uh, those rates and decrease it closer to around eight to 10%. Um, some of those techniques, you know, are tailoring the implantation of the valve and the depth, uh, and using different techniques for both the self-expanding and balloon expandable valves. Um, also tailoring it based on the patient's, you know, preexisting EKG, if they have a right or left pulmonal branch block, um, and oversizing or undersizing valve, uh, you know, immediate anatomy that could accommodate either size. Um, and taking into account the degree of LVOT calcium, you know, there are different things that we've kind of tweaked over the years. And I think that has helped to decrease the rate. And I think that's probably nationwide as well. Um, but yeah, roughly I would say within 30 days, it is close to that number. And, and so when, when you're, that's the numbers you're about seeing, um, is there anything that, that feeds into that where you can maybe decrease, um, permanent pacemakers? Uh, are you just through this detection? Um, is that changing? I mean, the, the, the detection of 15%, is there anything that's adjusting your pacemaker rate as well? Or not really? Yeah. You know, I think part of it too, and Rich can probably speak to this, you know, I think originally, uh, for patients with a bundle branch block, uh, we were doing a lot of BP studies and, um, there were cases, you know, where the patient was, let's say in the immediate post-op phase, uh, that they would qualify for a pacemaker, um, for balloon expandable valves, multiple studies have shown, you know, there is a transient edema, uh, or swelling at the implant site that can cause a conduction abnormality that subsequently resolves. And they've done studies on this where they don't require a pacemaker days later. So there was a patient population that might've been getting a pacemaker originally that needed it, but probably didn't need it in the future. So I think that is one of the areas where this MCOT has helped because we can kind of discharge these patients with the monitor, feeling comfortable that they're being observed and see truly do they had developed a conduction abnormality that would require a permanent pacemaker. So in a way, I think that helped to decrease our pacemaker rates. Thank you, Dr. Chahal. So as he referenced, Dr. Amara, knowing of course that these patients are discharged with a monitor and you have real time data analysis there, how has that impacted your clinical decision-making or treatments regarding permanent pacemaker implantations in TAVR patients? What has that changed for you? Sure, so speaking a little bit to what Dr. Chahal was saying earlier was that probably compared to maybe a couple of years ago, we tend to wait a little bit longer before performing our kind of evaluation, plus or minus EP study to see what conduction abnormalities might do because sometimes it is just due to inflammation and that can settle out and people's conduction can kind of return back to baseline. But that being said, I would say the risk, I think if we think somebody is at a significant risk for going into complete heart block, even if we discharge them with an MCOT monitor, that could still potentially be a serious adverse event or mortality, hopefully not, but it's possible. So I would say if we feel that there is a concern, especially if we feel concerned enough to do an EP study that additionally adds concern, I think we hedge toward putting in pacemakers on these folks. Because I think that being said, it's a really nice safety margin to be able to have the MCOT monitor and see how people do. But if I felt somebody needed a pacemaker in the hospital or if I felt strongly enough about it, I think we do it because even with a monitor, if something happens, that can be a really bad event. Thank you. That adds a lot of great context. I wanna reference something here for a minute. Medaxium did do a white paper. We mentioned it a little bit earlier in this webinar and it does feature the University of Maryland and this team. And so we just had that put into the chat. And so there's a link to that white paper there. So you can click to download that if you'd like. The purpose of that white paper and this webinar as well is really making sure that when we do implementations like this and create new programs, we're really focused on the entirety of the quadruple aim, right? So total cost of care, better outcomes, improved patient experience and clinician experience as well. My question, and maybe I'll start with you, Rachel, is how has this particular program that you've created with the University of Maryland, how has that impacted your patient outcomes and your TBT registry outcomes as well? So we, you know, all TAVR programs strive for the best outcomes they can have because obviously that's the best for our patients. I was the structural manager focusing on lots of different initiatives. When I left University of Maryland, it would be difficult for me to say specifically other than those 15 lives saved, that I know, but it would be difficult for me to say specifically how, you know, the MCOT program without the numbers in front of me changed our readmission rates or 30-day mortality, et cetera. Because I just don't have that at my hands right now. But I will tell you, as the nurse practitioner of the program, I was heavily involved with the patients after discharge up until the 30-day visit, 30-day follow-up visit. I also saw the patients at their 30-day visit. The patients loved that they had that protection. They felt safe. They understood why they were wearing the monitor. We started that education with our patients pre-TAVR. So when we talked to them about the risks and we talked to them about the risk of heart block, when we were consenting them for the procedure, they understood those things, along with their family members or support people. So when they had their TAVR and they got their monitor, they knew why they were wearing it ahead of time. But we use the monitor in many different ways to keep those patients safe through the 30-day period. So again, I don't have specific numbers. I know that our length of stay was excellent. Our, the procedure itself was, you know, has gotten so good, you know, and our providers are so good that, I mean, I had a patient once say to me, I'm not kidding. She said, I had manicures that were more painful than that. So, I mean, that's how good it got, you know? The patients came in, they went home and they were ready, you know, to start their life and it was exciting. So yes, I'm very passionate about this patient population, of course. And I still am, you know, that's why it's exciting what I do now, you know, is I get to see programs across the country and how they're doing things and share with them our, you know, we didn't do everything right. We don't have all the answers, of course, you know, but to get to collaborate with other program managers that are experiencing what I've experienced, it is really exciting. And then hearing the stories, the success stories. And we seek to really impact, you know, all those metrics that are tracking, but mostly patient safety and protection. Thank you. Dr. Chahal, do you wanna add anything to that in terms of maybe some of the processes that have been able to impact these outcomes? And if you wanna comment in any more specificity around, you know, registry outcomes, I'll leave that to you. Yeah, Joe, I think, you know, we'd have to analyze all the data, but overall, just looking at it, like Rachel was mentioning, I think we've clearly seen the length of stay has definitely decreased with MCOT monitoring. And I think the main reason for that has been, you know, our patients with the left bundle where we previously didn't know if they were gonna go for an EP study or, you know, what their course was gonna be. We'd keep them, get an EP consult, and, you know, obviously that would delay things in their stay. Now I feel, you know, we're a little more comfortable discharging them the next day with the monitor on. So I think the impact on the length of stay was probably one of the biggest things we saw in our registry data. I think the second important point, a lot of our patients, you know, we would leave in a temporary pacemaker, let's say if they did have a right bundle or a left bundle branch block. Now, going forward, you know, we've seen with MCOT monitoring, we've seen with MCOT that we are able to discharge the patients. We don't have to leave the temporary pacemaker in, send them to the ICU, which was, you know, taking up one of our ICU beds, which had been limited in the COVID era. But also the throughput of our patients, I think just the efficiency of the hospital from a cardiology standpoint has been increased. You know, we're able to get patients out sooner, get other patients in that have been waiting from our 10 sister hospitals, you know, for a bed here. And I think that's been one of the biggest things that we've noticed. Excellent. Yeah, length of stay and optimizing your program, it just, you guys have seemed to really tackle that with this new program around MCOTs and freeing up those resources is phenomenally important. Dr. Amar, I want to turn to you. There's a lot of ways that we can detect arrhythmias, right, event monitors, Holter monitors. Can you tell me about your choice for going with MCOT here and how that's kind of impacted your results and the improvements that you've really seen inside of your program? But why did you do MCOT? Sure. I mean, I think it's a pretty short and simple answer, which is that you really need to be able to analyze data in real time. Any of the monitors available that don't allow for real-time data analysis and very quick acquisition of that data through the website they have set up, I think just wouldn't work really, because it's not much good to be able to see weeks later that somebody had a bradycardic event rather than seeing it in the moment and being able to evaluate at that time and decide on what to do. So I think that's really the answer to that question. Thank you. I understand that completely. I don't even know if there's anything to add to that, but if so, Dr. Jehal or Rachel, do you want to add anything to that from Dr. Amara? I mean, no. I mean, obviously Dr. Amara hit the nail on the head that any device that's recording and that you're not going to have access to is not going to help. I will say one of the best things about MCOT specifically, our patients oftentimes would come back to me, if they're in their 30-day window, but it may be after still wearing the MCOT after it's been already turned off. And they would say, I was just keeping it here to give back to you when I saw you. And the beauty of it is, is we already had their end of session report. So we already had, Philips is able to give you the end of session report regardless of whether the monitor's returned. And so there was never waiting on that information. The doctors had access to it. The notifications came to us in a customized fashion, the way we wanted them. It was just, as we went through and we figured out what calls do we want? What calls do we not need at two o'clock in the morning? We were able to create a really good system that worked for all of us, but especially the patients. Excellent. I've got a really interesting question that's come across. I'm excited to ask it. Have you identified patients pre-TAVR who you suspect to be high risk for CHB post-TAVR and implemented a home monitoring system with the goal of validating pre-procedure PACER placement, which would not then impact your post-TAVR registry data? So identifying patients early, putting in a PACER early, because you can determine who's going to be really high risk. Have you guys gone down that path? And if so, what have you found? Dr. Shahal, I think I'll start with you on that. Yeah, Joe, no, we haven't gone down that path. I saw the paper on that where they did study that in a series of patients, but from our institution, we haven't actually explored that as an option. And Rich, you can maybe comment on that if that's something you think would be beneficial from our end. I would say what we have done is identified people who we feel are at high risk. And I know you guys alert us to those patients beforehand. And oftentimes we, sometimes we've seen those patients beforehand and we keep a very close eye on them afterward in the hospital, regardless of what we see on the EKG after their TAVR is complete. But we haven't been doing that. You know, I'm not quite sure whether or not we should be doing that, I guess is the best way to put it. I'm just not really sure at this time. I'd have to see how that bears out if other people are doing it with more frequency. You know, yeah, but I'm not really sure. I mean, a pacemaker is a big deal. You know, it's another thing we have to implant in somebody's body. You know, if we're not sure that they need it, you know, I'm not sure. I'm not sure, I guess, is the best way to put it. There's no guidelines exist yet for that, do they? No. Yeah. That's a phenomenal question. Another one has come in. Did you compare your pre-MCOT data to post-MCOT data related to the percent of patients admitted post-TAVR with CHB before and after? So has it changed, I guess, in terms of your admits, whether, you know, pre-MCOT usage and post-MCOT usage, have you seen that change in kind of admissions for CHB? Dr. Amara? Oh, go ahead. Oh, well, I don't know. Do you guys have those kinds of numbers? I don't know. I was gonna answer the question. So interestingly, we are doing that right now. So- I've analyzed some of that, go ahead. Yeah, so what we wanted to do is, you know, data collection takes time and let's be totally honest. Let me be totally honest. In 2020, when we launched our program, a lot of things about TAVR changed because of COVID. We, for the first time, we weren't doing as many TAVRs as previous because we were risk stratifying. People were afraid to come into the hospital. There was a lot of things going on. So our 2020 data was a little bit skewed. The patients that we did do were sicker. We didn't do as many, et cetera. And so then 2021 came and things started to get back to normal. So we are partnering with University of Maryland right now to take a look at this data, right? And so we wanna look at what was going on in 2019 prior to launching MCOT and then using 2021 into 2022 probably to take a look at all of those different KPIs. And it'll be interesting what we find. Thank you. So let me ask you this, and we have a little bit of time left. I anticipate more questions coming in, but if you were talking to folks as you are today who may or may not be considering implementing a similar program for post-TAVR clinical care, what advice would you give them? I mean, what is the final kind of parting words, if you will, on how they should proceed? Anybody can start. Rachel, how about you? So when I was a program manager, I really truly believed in doing the same thing the same way every time, as a way of promoting standardization, promoting patient safety. And so when we built our program, we truly believed that, especially initially, that we wanted to put a monitor on all of our patients who did not have an existing or a newly implanted pacemaker. We also wanted to build it as a program. We wanted to look at it from every which direction and make sure that every person knew what they were doing, what their role and how this was gonna work. And so the attention really was, and the important part was really in those details. So that's what made our program so successful. And once you implement something that's new, over time, it becomes automatic. And that was really what was neat about this program. Everyone from the unit secretaries who would register the patients to the physicians who were reading, to me utilizing it, and the nurses placing the MCOT, this became a very tried and true program. And that was what made it so successful. And even the patients, they knew, they were like, where's my monitor? I'm ready to discharge. They already knew they were getting their monitor. So again, that's what really makes a successful program is the time put into launching it. And that's pretty much what I'm thinking. Dr. Amara, what words of advice would you have? Sure. The only thing I can really comment is that it's been a pleasant experience. It's very, very easy for me to access and review and analyze the data. From the EP perspective, the ECGs from the MCOTs are super clear, very easy to look at, very easy to kind of analyze and figure out what's going on. So from that perspective, it's been very pleasant. Excellent. Dr. Chahal. Yeah, Joe, I agree. And like what Rachel was saying, I think you need an actual champion for this, your program, if you're looking to start it. Rachel was instrumental in getting this up and running and having a dramatic impact on our program by doing the MCOT monitoring. So I think that is definitely one key approach. The second, I think you definitely need the real-time detection, whatever it may be. So obviously, as we mentioned throughout this webinar, I think having a notification even 30 minutes to an hour later is too late. So as real-time as it can get is important. And then to tackle what Dr. Amaro said, I think just the ease of access to the record. So you can log in on your phone, quickly pull up whatever the alert may be, even as they're calling you. And it's organized in such a way that the newest alert is at the top of the page. You just click on it, you can see the rhythm strip, which is very clear. And so I think those are all key important points because a lot of these may happen in the middle of the night or while you're doing other things. So being able to handle that and juggle, taking care of the patient at the same time is very important. So I think that adds to the efficiency of it. Excellent. Thank you for that. I kind of want to reflect a little bit back on this implementation process too. Was there any big challenges that any of you faced that you had to overcome? Like what is the landmine that somebody could step on if they don't do it right? I would start off by saying we were very careful about when the monitor would be placed because a lot of concern comes, when the patient's inpatient, you don't want to be initiating an outpatient device. And so we were careful to plan how that was going to work. Making sure that the patient was officially discharged from the hospital system before activating and register. Well, they could be registered but before activating the device. We did not have any problems with billing. We did not have any problems with coverage. I was the person that the patients would call if they got a $5 bill for labs I ordered and I never got a phone call about the cost of an MCOT. So, keeping in mind, the majority of our patients are Medicare by, to have our patients do tend to be older. And so there was just no issue with that. So, that was really something we were careful about. The other thing we were super careful about was the staff, just making sure that they were re-educated. We would go back and re-inservice the staff. There's a lot of turnover, as everyone knows, with nurses. There's nurses coming and going at high rates right now. And new nurses on the units, new grads, travelers, they had to be familiar. We were very careful to make sure that they would get the information that they needed and that they would be oriented to the MCOT and how that worked. Our account executive was always available for questions, concerns, anything that wasn't working well. So, just like Dr. Shahal just said, this isn't the only thing we're doing, right? We're all extremely busy and pulled in different directions. And that's why the monitoring program just can't be a headache. But with careful attention on the forefront, it wasn't. Yeah, to echo what Rachel was saying, Joe, too, I think some of the things that we needed to take into account when establishing this program, who is gonna be getting the alerts in the middle of the night at 2 a.m.? So, we kind of had to set up a call pool of who would get those alerts, who would be the primary on the phone call, secondary if the primary person didn't answer. And I think those are all things that you work through as you're developing your program. But it was easy to assimilate into that. But it was easy to assimilate into our call pool for other things as well. Thank you. Dr. Amara, anything? I don't think I have anything too much more to add to what these guys have already said. Yeah, yeah. Okay, I've got another question about the PCP, so the primary care physician. What kind, if any, alignment needs to be done with the PCP when the patient leaves with a monitor? Are they going to visit their PCP and PCP ask questions? And how do you communicate that or any findings for the monitor? You know, how do you interact with the PCP in the context of the post-TAVR MCOT monitoring program? So, in TAVR, I would say our close connection was the referring cardiologist. So we paid very close attention to our referring cardiologists so that they, number one, knew about our program when we launched it. Our account executive actually was able to give each referring cardiologist practice a login to MCOT portal so that they would be able to see any data that they needed to. But we also would share records. Those end of session reports, we would always send back to the referring cardiologist if they had them for the record. And we also would discharge all of our patients wearing a wristband. That said, I had a TAVR at University of Maryland. And so, it sounds like a simple thing, but it really did make sense so that if the patient ended up at their PCP's office or wherever, they could call us if they wanted to ask us a question, they knew what procedure. And of course, we shared records with the referrings. The referrings usually then would communicate to the PCP. Now, if a PCP referred directly to us, of course, then we would share information. But to answer the question, we were very careful with communication back to the referring cardiologist. And those offices really appreciated that. Yeah, to echo what Rachel said, I think, yeah, the referring cardiologist was our primary contact. We have a great program administrator as well. So we would print out each of those rhythm strips. For something concerning, and write our interpretation on it and fax it over to their office as well. So they had it for their record. Excellent. Not to put you on the spot, but anything to add Dr. Amara or? I mean, not a huge amount, you know. Yeah. I know, I just, I didn't wanna leave you out. But this has been really educational. I appreciate you guys sharing your story. I appreciate you letting us capture it in a white paper, which again, if somebody logged on late, if you scroll through the chat or here we go, you know, it's there in the chat, you can access the white paper and download it. So I appreciate you giving so much and allowing us to share this success that you've been able to create for patients at your institution. Any final thoughts before we dismiss the webinar today? I'll start with you, Dr. Amara, if there's anything you wanna share. Again, no pressure on that, but these are closing thoughts at this point. Yeah. You know, just to kind of echo what we've already said and sum it up, you know, I think it's just from the electrophysiologist perspective, which I can speak to, it's been a pleasant experience, you know, easy to access the data from the MCON monitors, you know, very easy to interpret that data. And we've seen several patients already where it's, you know, helped in their clinical care. So, you know, I think that's all very good. Thank you. Dr. Chahal. Yeah, I pretty much echo what Dr. Amara said. You know, I think the ability to, for communication as well, you know, take a screenshot of this alert that we get on our phone and just send it to the EP doctor or Dr. Amara, you know, to be able to help get these patients in, get them a pacemaker sooner rather than later. You know, I think just the efficiencies in the system, and decreasing our length of stay has been dramatic. And I think we'll, like Rachel mentioned, we'll be studying this and getting that data out soon. Excellent, thank you. And Rachel, we'll give the last word to you. I think the only thing I would say is that, you know, I believe in this so much, you know, and I believe in taking care of these patients after discharge and utilizing this heart monitor so much that I was, I left the best team in the entire world at University of Maryland to spread the information that we know across the country. And so, again, you know, when building a program, it's just, it's very, it's not as simple, but it can be, you know, with the right tools, so. Well, thanks to all three of you for participating today. I want to thank as well, you know, Philips BioTel Heart for connecting us to be able to make this happen. And so I'm thankful for that reference to learn your story initially, and appreciate all of you participating today. Thanks for giving us your time, your expertise, your insight. And with that, we can conclude today's webinar. So thank you all very much. Thanks everybody for attending. And we look forward to seeing you on a future webinar or at a MedAxium conference. Have a great afternoon, everyone. Thanks a lot, Joe. Thank you.

post-TAVR MCOT monitoring program

University of Maryland Medical Center

heart block

AFib

early intervention

Mobile Cardiac Outpatient Telemetry

real-time data analysis

conduction abnormalities

communication with healthcare professionals