AtriCure, Inc. (ATRC) Earnings Call Transcript & Summary

Good morning, and welcome to the 2022 JPMorgan Healthcare Conference. I'm happy to kick it off this morning with AtriCure. I'm Robbie Marcus, Med-tech Analyst at JPMorgan. And very happy to have the CEO, Mike Carrel from AtriCure. And joining us later for Q&A will be Angie Wirick, the CFO for AtriCure. Mike, I'll hand it over to you in just a second, but as a reminder, I'll be -- you'll hear this a lot this week. Feel free to e-mail me or chat me on Bloomberg with any questions you have for management during the Q&A session. You can also go on the conference web page and submit a question to me as well. But with that, Mike, I'll turn it over to you and join you for Q&A in a little bit.

That sounds great. Well, thanks, Robbie, and welcome, everybody. I know it is early morning for those of you on the West Coast. We'd all love to be together at JPMorgan. I think that's something that I always look forward to every year is meeting up with everybody in person. But I think JPMorgan made a smart and correct call, and we will do best that we can over zoom. Hopefully, you'll get a better idea of kind of where we are at AtriCure. So I do know that you'll be following online, and I've got a kind of copy here. I'm now on Page 3, and I'll kind of start there on Page 3 of the document that's sitting in front of you that is self-directed. I think many of you know or those that are on the call probably know that what our focus is. Our focus is that we are really focused on reducing the Afib epidemic around the world. With that, that has been our mission for the last 10-plus years. It is something that we are passionately dedicated to. And we've got everybody in our business, all 900-plus people that are really going after this space. In addition to that, we do impact post-pain management using the ablation tools that we have, and that's become one of our fastest-growing pieces of the business, leveraging the channels that we've got in thoracic surgery to really grow that market and grow that build as well. And I'll talk a little bit about both of those today. If you look at what we're doing and you look at those markets that we're in, these are millions and millions of patients and billions of dollars of addressable market overall. And we feel like one of the things that really differentiates AtriCure is we go after markets where we're creating new standards of care. These are areas that people have not gone after before and they've not been successful in those areas, and we're really kind of creating that. I mean I'll go through kind of how that comes together. It's what really creates extreme differentiation for us in these areas because not only do we have great technology, but we back that with really sound clinical evidence behind it. And we have a strong portfolio that allows us to show and kind of win in various different ways. We can win in the long-standing complex atrial fibrillation market. We can also win in the pain management market as well. These are two areas that nobody else is really playing in today and helping those patients out. And that's really our focus is to really help patients that are not getting treated properly today. And we feel like we've got lots of novel technologies, as we mentioned on the page here with that deep clinical evidence that is behind it. And again, our goal is to change the standard-of-care in these areas to help these patients out. I'm going to move on to the next page. So let's start first with Afib. I mean Afib, as many of you may know, is a serious problem. I mean you think about atrial fibrillation and you probably know people that have Afib, your parents may have it or your friends. As we all get older, we're going to know more and more people that have atrial fibrillation. It affects -- we've got 33 million people on the page. It affects probably more than 50 million people around the globe. That is a lot of people. And very few of those are actually getting treated effectively today. It's one of the fastest-growing parts of the market. If you have Afib, why is it bad? Well, I think most of us know it causes stroke or has about a 5, 10x more likely chance of causing stroke. The reason for that is that the blood pools -- the blood typically pools in the appendage when your heart's not beating that properly, and that causes basically embolia form and then go into your brain and cause those strokes. That's what's causing it. It is detrimental to any patient that has to go through that. In addition to that, because your heart is not providing enough oxygen to the rest of the body, you also have a 5x more likely chance of getting heart failure. So another, obviously, terrible disease and terrible impact of atrial fibrillation. As a result of all that, you've got a 46% greater chance of all-cause mortality. In many cases, atrial fibrillation, at the onset, you are more likely to die within 5 years if you have atrial fibrillation, then you do have many cancers out there in the world today. And again, we are focused on and dedicated in basically reducing this epidemic because these are really awful, awful results of having atrial fibrillation. It is a big market. It affects a lot of us, and that is only going to grow. I'm going to move on to the next slide to kind of show briefly kind of about what that size of that market is. The U.S. market opportunity, we view as well over $3 billion, and it's about a $2 billion annual market on the international front. And so we're just scratching the surface in the markets that we're penetrating, and I'm going to go into a little bit more detail here on that. But if you look on the U.S. side of things, the things that we're working on is continuing to build a dedicated sales team. We've got over 300 people or so across all of our areas within the U.S. market that are dedicated to serving those customers in the hospitals, in the ORs. We support that with clinical evidence -- deep clinical evidence. We've got two PMAs today. We're working on several others. We view that as a way to differentiate the company going forward and bringing new products to market on a regular basis. On the international front, we've got to enter into some new markets. We are very strong in the Japanese market in China and throughout Western Europe, but we do distribute through 50 countries throughout the world. So we're going to continue to build and grow within those areas, again, very large market opportunities. So to break that down just a little bit for you, turning on to the next -- I'm sorry, before I do that, maybe I'll walk through quickly how does atrial fibrillation present itself? And why are we differentiated in the areas that we're in? So typically, when a patient comes into the market and they're sick, And what they've got is really -- I'm going to break it up into two different pathways. Pathway #1 is a patient has atrial fibrillation and they also have some other disease like they've got to have their valve replaced or repaired or they have coronary bypass that is, we call that our open business. And so they've got structural issues they've got to deal with and they also happen to have atrial fibrillation. We also have part of our business that is you have no other structural issues, all you have is Afib. The structural part, if you have to go in for open heart surgery and you have AF, 1/3 of those patients around the globe have atrial fibrillation. That is a market that we are the leader in the world. We've got a PMA for the differentiation there. And the guidelines supported. Yet still to this day, as I'm speaking to you on this phone today, still only 25% of those patients are getting treated. Now that number is great. Over 10 years ago, 12 years ago, that number was 10% or 12%. It's improved dramatically with education and training and the PMA results that we got. But we've got a long ways to go, and we think we've got some strategies by which we can take it from 25% to that next level. On the other side of the coin, you've got a patient that does not have those structural heart issues and all they have is Afib. That patient tends to go in. And when they get diagnosed, you try to do drugs first. When the drugs don't work, that patient kind of breaks down into, you've got to do some sort of therapeutic on it. Well, in the earlier stage of atrial fibrillation, there are great catheter companies that many of you all know, and they do wonderful jobs of treating that early stage or what many people call paroxysmal atrial fibrillation. I look at it a lot like cancer. It's the early stages and that catheter works incredibly well for dealing with that. As the disease progresses, so as it moves outside of the veins and into the rest of the heart or the atrium, it becomes much more complex to deal with just the catheter. And so what we are is we're really going after that persistent and especially the long-standing persistent market. These are patients that have been in atrial fibrillation for over 1 year. 45% of all patients fit within that category. That is a large pool of patients that are not getting treated properly today. And in that area, we are the only ones in the world who have a differentiated label in a PMA with our CONVERGE trial. And that is our hybrid stand-alone procedures. Now we're not taking away or competing against the catheter. Because in our procedures, a catheter is being used. And so you're kind of adding to the armamentarium of the EP in this case, by adding the surgical technique that we bring to the table. So this is kind of how that patient flow works. And that market is really underpenetrated today. If there are almost 4 million patients in that population today, only 3,000 of those patients were treated using a combination technique over the last, call it, 12 to 18 months. We have a long way to go to help that patient population out. The CONVERGE approval allows us to get there, and I'll talk a little bit more about what the data looked like within there. So moving on to the market opportunity, maybe diving into a little bit more detail here. I'll start with the right side, which is the $2 billion and growing opportunity of what I was just talking about, which is that stand-alone hybrid procedure. When you look at that market today, in 2019, there were 180,000 catheter ablations for atrial fibrillation across the board. And of those, 25,000 were being done on long-standing persistent patients. Well, they were mostly done with catheters. I just told you that there were 3,000 patients that were basically being treated with some sort of hybrid form. All of those patients, every single one of them, will get additional benefit by adding our EPi-Sense technology and the CONVERGE procedure to that, and I'll show you the demonstrated results that show that out. If we can just get to that, you're talking about a $250 million to $300 million a year market, just with that, let alone the fact that there are 3 million to 4 million patients that have long-standing persistent atrial fibrillation. So the patient pool is huge and that 25,000 should grow at a much larger rate in terms of the treatment on there because there are so many of these patients. And so we really believe that, that is a huge market opportunity that could grow to multiple billions when you add the growth of it, attaching ourselves to that, that already exists today. And on top of that, adding appendage management to that. By appendage management, we've got something called the AtriClip, where could you put that on at the same time that you're doing that procedure. It has additive benefits to that. And we believe that you combine those two and you're talking about a multibillion-dollar market opportunity over the next 10 years. Now our open business that I referred to before, has steady growth. It's been a very good contributor. And we also have a new product coming in the market. Now again, we are the only player in the market, the only ones with a PMA approval in this area. In the U.S. alone, there are 300,000 patients that undergo cardiac surgery. Of those 300,000 patients, about 90,000 have Afib. And only 25,000 or so are getting treated. That number should be closer to 70,000 patients getting treated. And that 300,000 number, while many people say that is not growing, it actually is growing every year at 1% to 2%. So we've got a market that's growing. Our penetration is incredibly low, and we believe that we can come out with new technology. We're coming out with something called the EnCompass technology for -- to treat most of those patients. We've got the only PMA label. And recently, reimbursement came in here and actually added significant reimbursement, so that they actually do better at a hospital level as well, not only at a patient level to treat these patients. So I believe over the next 5 to 10 years, we've got a huge runway to basically take that 25,000 and make it 50,000 and 75,000 patients that will get treated on an annualized basis. Big market opportunity and growth opportunity for us at AtriCure. And then finally is on our pain management business. Our pain management business, I'll talk a little bit more detail about it later, but basically, it's ablating the intercustomer for reduced pain after surgery. and it's used in conjunction with other techniques like epidurals or exparel and products like that, that can reduce it temporarily, ours last about 6 to 8 weeks. So it's additive to that. These patients recover more quickly, have much less pain, their quality of improvement and how fast they basically improve after the surgery is dramatic. And in the United States alone, there are 150,000 patients that undergo thoracic procedures. This year, we did about 9,000 -- 9,000 to 10,000 or so patients. So we're just scratching the surface on this market. We're less than 10% penetrated in here, and this product works incredibly, incredibly well. And it's one of our fastest-growing parts of our business. In addition to that, we just got approval in Europe, and we'll be expanding our team in the European market as well. So big market opportunities that we're going after, and all of them are untapped and we believe we've got a nice decade ahead of us for growth. It really leads me to the next slide on Slide 8, which is we've made a lot of progress over the last decade, setting up what I just talked about, these big markets and these big opportunities to really treat and help patients that are not treated today. It started in 2011 when we got our first and we were the first to get that PMA approval for that open concomitant treatment with our synergy clamp. And over the last 10 years, we have invested heavily in additional clinical science, bringing out new technologies with our Clip franchise and the multiple iterations to make it less and less invasive and more and more effective over time. In addition to that, while that's happened, guidelines have changed, reimbursement has changed, all to the benefit because treating these patients helps, and we've helped over 300,000 patients during this period of time. And that leads you to 2021 when just in this most recent year, we got the CONVERGE approval with that large hybrid market opportunity. And I'm going to go through the data here in a moment. You've got the added benefit of the Cryo Nerve Block that I just talked about, where we more than doubled the size of that business over the last year, and we've added significant resources to get ourselves market access in that area. And then we've also got 510(k) clearance for our open concomitant EnCompass product that will, I believe, make it more efficient and easier for surgeons that were a little hesitant to use technology before to really enter into the space and do it seamlessly. And that product is now just beginning to roll out. So we've got lots of shots on goal to win with, and I believe we've set ourselves up for a decade, a decade of strong growth in these areas where we've got extreme differentiation. So moving on to the next slide, what does that mean for our priorities for 2022? If you look at those three different categories, on the open side of our business, really, if you start off on the left, in addition to the EnCompass clam, which was just cleared and we're going to be launching that, we're also going to be launching a trial that we've talked about called LEAPS. The LEAPS trial is so that is for managing that left atrial appendage. There's recent data that came out with a trial called the LAAOS trial, and that showed that by managing the appendage, you can have a significant reduction in stroke in atrial fibrillation patients. Dr. Whitlock did a wonderful job of organizing and doing that trial, and they use multiple techniques for managing the appendage during that. We are taking that up to a whole another level, which is to prophylactically manage that appendage. And take that appendage out of commission. So that when that patient in that patient lives for 20 years, they're not going to have to worry about their appendage. And our goal is to show and prove that you can reduce stroke, you can reduce hypertension also by managing that patient population and manage the appendage within there. Now this is doing several things. One is a proactive move forward to help patients that are not getting treated today in this area. It expands our market opportunity dramatically by basically saying, all 300,000 patients effectively in the U.S. and 900,000 globally could possibly get it. And that LEAPS trial is going to, we believe, definitively prove that. And in 2022, we believe we will get through and get that approved to go into market. It's going to be about 6,500 patient trial. It will be a randomized controlled trial between patients that do not get a clip and those that do get a clip. And we believe, again, this is going to expand our market opportunity. In addition to that, it's going to set the bar really high for anybody that wants to enter into this market. We're saying that we are committed to showing the stroke reduction benefits of our clip, and we're going to show it in the most complicated and difficult to treat once this prophylactic treatment. So again, this is a market-expanding opportunity and it's doing it with sound, strong clinical evidence in a large clinical trial, one of the largest it's ever been done in cardiac surgery. I mentioned earlier about the EnCompass moving off to the right and the EnCompass clamp -- what the EnCompass clamp does is it makes it easier for that coronary bypass surgeon who was not comfortable getting behind the heart to put one clamp on to do a really fulsome ablation on that patient's part. And we believe it makes it more effective and easier, and we've been rolling it out. We've got over 100 patients already that have been treated with this. We've got lots of learnings from that, and we're beginning to roll that out kind of more globally throughout the United States and then we'll go outside the U.S. But right now, it's focused on the U.S., that 510(k), and we believe that should have an impact on our growth in 2022. Next is our pain management business. The biggest focus there in 2022 is expanding the team. We know the product works incredibly well. We've got over 30 people on that team today, and we are going to expand that aggressively as we get into more sites, more centers throughout the country. As they try it, they wind up expanding it within their hospitals and we believe that growing the commercial team and growing the support infrastructure for that team is going to be critical in 2022. And then finally, on the hybrid side is expanding sites and getting really deep within the sites. We've had an amazing amount of training over the last 6 months since the approval. It's been better than I ever expected. CONVERGE has been really well accepted out there in the marketplace. We've gotten great feedback from people. And we are going to continue to both increase the size of our team, adopting new accounts, and we are going to train, train, train and get people up and running within that area. And we think that that's going to be something that's going to grow this business again for many years to come. That's our focus for 2022. We'll come back at conferences in the future in times that we talked about on earnings calls, about what that looks like and why we're making progress within each one of these different areas. So what that leads you to, though, is let me talk a little bit about CONVERGE. And what the results showed us? And many of you may know some of this, but it's really good to repeat and get a reminder. We are the only ones in the world with a long-standing persistent Afib patient label, the only ones in the world. It represents 45% of all patients in the United States. We can sell this in the U.S. and in Europe. That provides extreme differentiation. It doesn't compete against the catheters. It's additive to the catheters. And when you combine it to the catheters, you get superior outcomes. And if you look over to the left, you can see what those outcomes look like at both 12 and at 18 months. We had over 100% improvement between the two different arms. That is dramatic when you're adding that up and you're looking at that patient population. Not only that, but it lasted out to 18 months and was incredibly durable. And I'll talk about in a moment, another benefit, which is significant burden reduction when you compare the two arms in it as well. Now one of the other benefits, though, has been the efficiency. So in addition to being better for the patient and faster, that you can get out of the EP lab and use less EP time. So today, when a physician wants to treat this patient, they could spend 4, 5, 6 hours trying to treat the patient in ablating the back wall. We can take that down to an hour. In the trial alone with a reduced set for them, where they weren't attacking it for 4 or 5 hours, they -- we actually save them 40 minutes of time. But we see in practice that is a lot more and even 40 minutes alone is significantly sort of adding the number of patients. You can treat a lot more patients with that and you're getting better results. So you're getting better results, and it's more efficient for the EP lab. And we believe that's a winning combination when you combine those two together. Moving on to the next slide. Some of the other benefits that you get and why does it work is because what you're seeing is the endocardial catheters again, do a great job of isolating the veins and attacking things from the inside the endocardial. But they can't always go all the way through and get a transmural lesion because it's dangerous to get to that backside and it's different tissue profiles on it. So when you combine ablating from the outside in and you're sandwiching it like that, you get much better results regardless of the technology that you're going to be using. We used RF within the trial, but we see people that are using cryo with it as well, and it works incredibly well when you combine the two technologies. And we see a significant improvement, obviously, when you do that. I mentioned earlier about the burden reduction and the burden reduction is dramatic. It's a 90% burden reduction when you actually combine the two as well versus just doing it all by itself. So what you're seeing is that these patients do better. We have not studied how -- whether or not they live longer, but we do know that they are getting out of atrial fibrillation and they're actually feeling a lot better when they leave the OR and for many years to come. Moving on to the next slide, a little bit about our commercial strategy. Say, okay, Mike, if it's bad, Convergent works incredibly well and has great results. How are you guys going to market with this? So we're really targeting specific accounts first and foremost, that we know that have EPs that are progressive and are open to this, and we've had lots and lots of accounts to it. Quite frankly, throughout this process, I've been surprised that we thought we'd get some feedback that would have been pushed back against us when the results came out. We've gotten none of that. Almost every EP recognizes the results were done in a sophisticated way. The results look really good. We need to create that awareness and get to those first sites that we can get up and running where you've got an EP that they can work with a very strong cardiothoracic surgeon, combine those two in that hybrid setting, that's kind of step one. But then we've got to train and develop these programs, and we are booked. We've got mobile labs running around the country. We've had two. We are oversubscribed on those. We're moving to a third and they are absolutely booked out for many months to come. And that's the kind of demand that we're getting. These are trucks that travel around the country during COVID that allow for us to be able to train at their site to get them up and running. And every one of those sites that we train, it's a building block to basically moving into the future. Now on top of that, we are going to leverage and add AtriClip. So we know that there are benefits for managing the left atrial appendage. There are many, many studies that are out there with that. And when you add the appendage to that, you both increase the ASP of the overall procedure, but you also do better for the patient. And a lot of people are actually leading with that, and they want to manage the appendage at the same time. And that actually is a really core and key component to the conversation for treating that atrial fibrillation. On top of that, we're expanding the team. So we're at almost 50 people or so today, about 45 or so people within this team. That number is going to continue to grow, and it's going to grow quite quickly in 2022. We expanded quite dramatically in 2021, and we're going to continue to add to this part of our headcount on the sales team as we grow this team. And then we're going to begin to create and amplify and do more awareness campaigns, and we're going to add therapy awareness reps out in the field as well to talk to the cardiology community and the internet community about understanding the data and that these long-standing persistent patients, they do have an option and their option is the conversion procedure. Moving on to the next slide. And hopefully, that gives you a good sense for why we believe and what we see within the Convergent area and why we think that's going to take off and going to be a huge, large market opportunity for us, but AtriClip has been known for many, many years. And as I mentioned earlier, we've got a strong portfolio of products across all different avenues. I talked about hybrid on the open side. We've got the EnCompass client that's coming out. We've had many iterations of the AtriClip product down on the bottom. As you can see it, it's become less and less invasive and it works incredibly, incredibly well. And on AtriClip franchise that is going to be included in the LEAPS trial is going to be the open-ended clip as well as the closed-end clip that we get. And there will be more technologies that's coming. We've got a great pipeline. Our R&D pipeline that's going to continue to make things easier to use, more effective and less invasive. Moving on to a spotlight on Cryo Nerve Block. I touched upon this briefly, but just to give you a little bit more color behind it, you can see the probe on Slide 14. The ball tip at the end of that, we bring nitrous oxide and you can basically ablate the nerve endings there or the nerve during any kind of thoracic procedure and that deadens or reduces the pain. And that typically lasts, as I mentioned, about 6 to 8 weeks or so post-op where you will feel very little pain because you're blocking that pain signal. And it gets cold enough to [indiscernible], but it doesn't get so cold that it kills off the [indiscernible], which would then do permanent damage. And that's really important as to why that nitrous oxide works very, very well, and it lasts and people are adopting this across the board at centers. And we are in every major cancer and medical centers throughout the country is either using it or in testing of this technology today. So we're feeling really good about the expansion of that. We've added many new sites this year, and we're going to continue to expand our team. And what you've seen is a substantial growth in revenue in this area as well, where we're well over $20 million in revenue, and you'll begin to see us break that out and talk about that specific revenue profile as we move forward. So Cryo Nerve Block is another lever for growth and strong growth for AtriCure as we go forward. On the EnCompass side, which is the open side of our business, I mentioned that earlier. We did get our 510(k) clearance. We did a limited release in the fourth quarter to give you an update on that specifically. And then as we move forward into this year, we're now expanding that release. And by midyear, we'll be in kind of full-on launch of that product. We like to do things in a very pragmatic and methodical way because patient safety and training is of utmost importance as you're rolling up new therapies. And that's exactly how we're addressing and looking at the EnCompass launch into this open platform. And everybody uses it and used it, has enjoyed it. It's working very well, and we're getting great feedback on how to better train going forward. I'll just touch upon real quickly some key investments for growth on Slide 16. I mentioned earlier that we have -- we dedicated ourselves on the innovation side, clinical science and education. We've got a large team. You can read the numbers on there that is dedicated out in the field. And then moving on to Slide 17, just to kind of see some of the history of growth that we've had as a business. You can see this year, we were over 30% growth that we announced. And we are -- we've given out our guidance and put our guidance for the year at $315 million to $330 million of revenue, which represents an acceleration against our CAGR from the 5 years pre-COVID and gets you to $315 million to $330 million or 15% to 20% overall growth. So we're excited about our future. We're excited about the platform that we built, and I'll turn it over to Robbie to ask any questions that you ask.

Yes. Thanks, Mike. There is clearly a lot of great things going on, but I did want to sneak in a few questions. On the topical information you put out today, specifically fourth quarter and the 2022 guide, as you mentioned, maybe we could start with fourth quarter. You beat Street consensus by a little bit in the fourth quarter. I imagine there were a lot of ups and downs, some areas you really outperformed some others where you had to fight for every bit of revenue in the quarter. Maybe just walk us through the trends, what you saw how it progressed over the quarter? And I think what investors are really interested about is the exit of the quarter and what that means for first quarter of 2020?

Yes. I think, I mean, when you look at our quarter, it was pretty consistent throughout the quarter. We definitely -- we get Delta and staffing issues at the beginning of the quarter, and then you saw Omicron kind of really kind of come in hospitals that were trying to protect some of those ICU beds definitely kind of moderated some of the cardiac surgery. So where we saw really good strength interesting enough was in our Cryo Nerve Block and in our hybrid area where we saw great strength in the quarter. Our open business was a little bit -- it actually had a fine quarter, but we would have expected a little bit stronger. That's where we felt a little bit more pressure overall. And that was because they were basically monitoring the beds in the December timeframe as they were getting ready and prepared in certain parts of the country. That was not everywhere, but in certain parts of the country, especially in the Midwest, where you saw Omicron and Delta really kind of rage even into the December time frame. You definitely saw an impact on case volumes on the open side of our business.

Got it. How do we think about Omicron? We've seen the cases rise. We've seen hospitalizations tick up, especially on a national basis. How are you thinking about -- and maybe this is for both of you, how are you thinking about COVID trends through 2022 and especially in the first quarter, as you've incorporated that into your guidance range? I would say most investors probably didn't expect a whole lot of guidance at the conference here. So you clearly have some assumptions of how COVID will play out in 2022. How should we think about first quarter and for the whole year and what's in the guidance range?

I think it's a great question. I mean we feel really good about the catalysts that we've got in our business. As I talked about, Rob. We've got so many catalysts that are really ready to take off. There is a little pressure on COVID the beginning part of the year. I think that you're exiting this year and in the early part of Q1, in a lot of ways, it's similar to some of what people saw to some degree last year, but I did -- not as bad, but I definitely you see some pressure in the early parts. But I think we're going to get through that here in the January timeframe and begin to see some upticks. We're already starting to see some of that a little bit where you're starting to book cases and see a little bit of an uptick kind of at the end of the month and into the next months throughout the quarter. So I think what -- we baked that into our guidance where we said, "hey, you know what, we want to have a little bit of COVID effect of that in the kind of call it the early part Q1 timeframe and then really beginning to break out as the year kind of goes on because we've got so many strong catalysts that are there that we believe that's why we were able to and comfortable to give guidance for the year.

And maybe just one last question on the guidance here. The Street is basically flat in first quarter with the fourth quarter. Do you feel comfortable with that as you sit here today?

I'm not ready to give the first quarter guidance quite yet. But I mean, I think that the numbers are out there are reasonable relative to kind of [indiscernible] today But there's a little pressure in the January timeframe, I think, overall. But I think we're going to have a great -- I mean, I think that you'll start to see that alleviate in the coming weeks.

So if we switch to CONVERGE, this was a -- you talked a lot about in the presentation, very differentiated label. You really started launching it throughout the middle of this year into the end of '21. '22 is when investors really start to see this showing up more meaningfully in the numbers. So maybe walk us through what you're hearing in the field? How the training is going? How the adoption is going? And maybe some early experience from centers that have picked it up so far?

We've had great adoption and great reorder from it. The feedback has been -- we -- all of our courses have been sold out for lack of a better word, even though we don't charge for it, but I mean there behave been back. We've had to continue to add extra courses. More and more people want to get trained. So that's why we've ordered the second lab because we're getting so much demand to bring these trucks and bring the training to them because not many of them can travel right now with COVID out there. And so they're really appreciating us doing that, and we have that being delivered here in the February time frame our third lab. So we're getting a lot of really positive feedback. The programs are beginning to develop and then get their patient flow to go. Now obviously, they're all having to deal with COVID as well. So throughout all that, they're trying to manage all that. So it even better if there was no COVID. But even with COVID, we're seeing actually a lot of activity, a lot of net new sites and getting deeper within every one of those accounts. And so it's been a real positive. As I mentioned, we're not getting a lot of negative feedback about the procedure from just about anybody.

Got it. So how is the scheduling going? Is that a hiccup when you start to train new centers? Because obviously, there is the surgeon component and then also the interventional cardiologist component. So how does this ....

Yes, it's a good question because what we're seeing is the trial was same day, but what we see today is that we're moving more towards probably closer to 80% or staging it. It used to be about 60%. I'd say a lot of the net new centers that are coming on board, because of the reasons you just described from a logistics standpoint or maybe philosophically, they want to see the atrium basically settled down a little bit after the first procedure before they go back in and map. Those two things are really driving people to do a staging at it. We're agnostic to it. It doesn't matter to us. The trial was obviously same day. But if they choose within their logistics to do it that way, when we're sensing that more and more people are doing it that way for the logistical reasons that you mentioned.

And as we think about these new centers that are coming on, are they centers that were in the original trial? Are these totally de novo centers?

These are all de novo centers. The centers that are in a trial are tried and true experienced, and they've already got really good programs up and running. So there were only 27 centers that were basically in the trial, and we've got hundreds of centers that are basically leveraging and using the product today. So we're really making great progress on that front. And these are all -- most of them are net new centers that were not part of the trial.

A couple of other products I want to touch on just before we close out. The Cryo Nerve Block has gone from 0% of sales up to almost 10% of sales in the U.S., really fast. You're going to be launching in Europe soon. So maybe a better question is, we've seen really fast adoption here. How do you think about this over the long term as a portion of the business? And can this be one of the key drivers of growth going forward?

I think it is. It's been -- if you were to ask me 5 years ago, would it grow this fast? I would not have guessed it. But the -- it works incredibly well, Robbie. I mean, the patients really benefit tremendously. And so we're really -- we're going all in on it because we think everywhere we go, we wind up seeing adoption, and we want to see continued orders from those sites because it's working so well. So that's why we're adding to the sales team. We do think it's a big driver. Now you get less per case. So you have to do a lot more cases. So I mean you have to balance the fact that we get $2,600 per case for it. So you have to do a lot more cases to make this work to have that kind of growth. So -- but it's a very fast and strong growing piece of our business, and I think it's going to be for the next decade. And eventually, I mean, right now, we're just in thoracic. You can imagine that 5-plus years from now, once we create the standard-of-care within thoracic, this could be used in other areas and other surgeries that we're beginning to explore and to look into right now.

Got it. Maybe touching on AtriClip. You have the PRO V launching throughout last year and this year. What's the feedback been in the field? And where do you see it as a percentage of mix going into 2022?

Feedback has been great. I mean, the more and more people are doing it just because it's easier to use. You've got more adaptability and movement with it. Actually, the handle is also a lot easier to use in terms of the deployment tool. And so that actually is where we're seeing a tremendous and most of the growth. We still -- people that used the old ones still like to use it. It works incredibly, incredibly well. And it's a little less expensive, so they might choose to continue to use that for a while. But we're seeing more and more adoption and movement down that path. I don't know that Angie might have the exact numbers about the split between the two. I don't know the exact split between the two off the top of my head.

Yes, I'd say on the open clip side, the usage is about half. I mean, the V clip has been well adopted. On the MIS side, I think we're still transitioning, I wouldn't say quite half yet but approaching that.

Great. Maybe one last question before we wrap it up here. You have a lot of growth drivers this year. You obviously gave really good guidance to start the year off here. This is a company you've been headed towards 20% growth potentially over time. as you look out 5 years from now, how do you think investors will view AtriCure? Are you within the same product lines? Do you have ambitions beyond? And what kind of long-term growth profile should investors think about for your company?

Yes. I think when you look at us, I mean, over the next decade, if we do nothing else, we can grow at really outsized growth rates with the platform and the products that we've got today. So if we don't -- if you think about the things I just talked about on the call today, whether it's the new trial with LEAPS and the existing clip technology and expanding that market with an existing product to CONVERGE and to the pain management, there's just a lot that we have right now in term to really grow. Now that being said, if we saw something that was complementary and that could accelerate our growth, we might look to doing something within the more interventional side of things. but it would have to be really compelling and it would have to be something that could really kind of help us expand and accelerate the overall growth of everything we've got because we don't want to mess with what we think is a very strong portfolio as it is today that can drive the kind of growth that you're talking about.

All right. Well, that's a great note to leave it on. Mike, Angie really appreciate you taking the time today, and hope you have a great day.

Thank you. Have a good one. Thanks, Ron.

Thanks.