Earnings Labs

AtriCure, Inc. (ATRC)

Q4 2023 Earnings Call· Thu, Feb 15, 2024

$28.59

-1.55%

Key Takeaways · AI generated
AI summary not yet generated for this transcript. Generation in progress for older transcripts; check back soon, or browse the full transcript below.

Same-Day

-4.36%

1 Week

-1.90%

1 Month

-7.89%

vs S&P

-11.91%

Transcript

Operator

Operator

Good afternoon, and welcome to AtriCure’s Fourth Quarter and Full Year 2023 Earnings Conference Call. At this time, all participants are in a listen-only mode. We will be facilitating a question-and-answer session towards the end of today’s call. As a reminder, this call is being recorded for replay purposes. I would now like to turn the call over to Marissa Bych, the Gilmartin Group for a few introductory comments.

Marissa Bych

Management

Great. Thank you, and good afternoon. By now, you should have received a copy of the earnings press release. If you have not received a copy, please call 513-644-4484 to have one e-mail to you. Before we begin, let me remind you that the company’s remarks include forward-looking statements. Forward-looking statements are subject to numerous risks and uncertainties, many of which are beyond AtriCure’s control, including risks and uncertainties described from time to time in AtriCure's SEC filings. These statements include, but are not limited to, financial expectations and guidance, expectations regarding the potential market opportunity for AtriCure’s franchises and growth initiatives, future product approvals, clearances, reimbursement and clinical trial outcomes. AtriCure’s results may differ materially from those projected. AtriCure undertakes no obligation to publicly update any forward-looking statements. Additionally, we refer to non-GAAP financial measures, specifically revenue reported on a constant currency basis, adjusted EBITDA and adjusted loss per share. A reconciliation of these non-GAAP financial measures with the most directly comparable GAAP measures is included in our press release, which is available on our website. And with that, I would like to turn the call over to Mike Carrel, President and CEO.

Michael Carrel

Management

Good afternoon, and thank you for joining us today. 2023 was an exceptional year at AtriCure, and I am proud to report a strong finish with fourth quarter growth of 21%, showing robust momentum throughout our entire business. Our full year revenue of $399 million represents 21% over 2022, our third consecutive year of above 20% revenue growth, and globally, we saw increasing adoption of our broad portfolio of products for the treatment of atrial fibrillation, the left atrial appendage, and postoperative pain. Our patient impact extended further than before, resulting in the achievement of our one millionth patient treated with AtriCare technology. In addition, our top line performance and increasing leverage drove $19 million of positive adjusted EBITDA in 2023, making significant progress towards sustained profitability throughout our business. Before sharing operational highlights of the fourth quarter of 2023, I would like to frame the opportunity in front of AtriCare now. We identify markets where patients are underserved and create standards-of-care to improve these patients' lives. We know that creating new standards-of-care requires sustained investment in innovation, clinical science, and comprehensive education and awareness. Investing across these areas has allowed us to unlock new opportunities over the last two decades, and we are now positioned to offer solutions for millions of patients worldwide. This translates to a more than $5 billion global market opportunity today, with significant potential to expand our market opportunity in the future. AtriCare is in a unique position as a leader in each of our markets, with every market still significantly underpenetrated. Therefore, we remain focused on driving adoption, as well as identifying and cultivating new opportunities to drive strong growth for many years to come. As such, we are reiterating our expectations for full year 2024 revenue of $459 million to $466 million, reflecting…

Angela Wirick

Management

Thank you, Mike. Our fourth quarter 2023 worldwide revenue of $106.5 million increased 21% on a reported basis and 20.5% on a constant currency basis when compared to the fourth quarter of 2022. U.S. revenue was $88.8 million, a 20.1% increase from the fourth quarter of 2022, reflecting robust activity across each franchise, highlighted by an uptick in adoption of our Hybrid AF therapy representing 30.6% growth for the quarter, along with continued strength from key appendage management, open ablation, and pain management products. International revenue totaled $17.8 million, up 25.8% on a reported basis, and up 22.1% on a constant currency basis as compared to the fourth quarter of 2022. We continue to see strong demand for our differentiated solutions in major international markets with significant growth in appendage management and pain management. Sequentially, worldwide sales grew $8.3 million, or 8.4%, over Q3 2023. Gross margin for the fourth quarter 2023 was 74.9%, up 94 basis points from fourth quarter of 2022. The increase was driven primarily by favorable production efficiencies, partially offset by less favorable geographic and product mix. Fourth quarter 2023, research and development expenses increased $7 million, or 51%, and SG&A expenses increased $12.2 million, or 22%, over the fourth quarter 2022. Turning to the bottom line. We drove positive adjusted EBITDA of $4.8 million for the fourth quarter 2023 compared to positive adjusted EBITDA of $6 million for the fourth quarter 2022. While we are continuing to drive improvement to gross margin and realizing operating leverage in our commercial and administrative infrastructure, we experienced a significant increase in research and development costs in the fourth quarter of 2023 due to the rapid enrollment and expansion of our LeAAPS clinical trial and multiple product development initiatives underway. Our loss per share and adjusted loss per share…

Michael Carrel

Management

Thank you, Angie. I would like to close by congratulating our entire team on an incredible 2023. Patient outcomes are our guiding principle and we are most proud of that at AtriCure. Your teamwork led over 100,000 patients treated this year and over 1 million in our company's history. We are making a difference for patients with advanced forms of Afib, higher risk of stroke and pain after surgery. As we grow and evolve in the future, patient outcomes will continue to drive our efforts as we capitalize on our leadership in these markets. And with that, I will turn it over to the operator for questions.

Operator

Operator

Thank you. [Operator Instructions] Our first question comes from the line of Robbie Marcus with JP Morgan. Your line is now open.

Robbie Marcus

Analyst

Great. Thanks for taking the question. Congrats on a good quarter. I wanted to start on the Clip business and minimally invasive, had good fourth quarters, beat expectations. Just -- you kind of talked about it broadly, but maybe a little more specifically, how you're thinking about those two relative to open and pain as we progress into '24.

Angela Wirick

Management

Yeah, Robbie, thanks for the comments. I think as you heard in the scripted comments, when we look at the guidance for the year, our expectation is that in the U.S. the growth rates of each franchise are pretty tightly coupled around the corporate average. I think unlike what we were saying in 2023, based on kind of our expectations of the year of having some franchises as outperforming and some franchises kind of falling below the corporate growth rate, given the progress within each franchise and kind of development opportunities would expect them to be more closely aligned around the corporate growth rate.

Robbie Marcus

Analyst

Great. And I guess I have to ask, just given all the investor angst around your competitor Medtronic launching and AtriClip competitor, what you're seeing so far in the field in 2024 so far, how the salesforce is reacting to it and any feedback you have from physicians? Thanks a lot.

Michael Carrel

Management

I appreciate the second question there, Robbie. I'll handle it from a couple different angles. I'd say first is just a reminder, we welcome competition. We think it's actually a really good thing and validates the market. And what I mean by that is that there -- as we talked about, we're still less than 5% penetrated in the overall worldwide market. There are over 2 million patients that undergo cardiac surgery worldwide. Less than 5% or so actually have an AtriClip or their appendage managed today. We have really big opportunities in front of us as we continue to invest in innovation. We're talking about the FLEX Mini product coming out later on this year, which is our eighth generation of the AtriClip product. In addition to that, we're investing in clinical evidence with the LeAAPS trial to show a stroke reduction for patients that are undergoing cardiac surgery. So, we're making the necessary investments on those particular fronts. We are seeing Medtronic and their Clip out in the market. And we think it's great that they've actually made that kind of investment. We do see people trialing it out and using the product. But we also feel very confident that we have a superior product today in the market with our FlexV product. And we feel like with the innovation we're coming out with the FLEX Mini and others, we're really well positioned to manage competition that comes into the market. We don't think they're going to be the first competitor in any of our franchises. One of the things for AtriCure is that we are dedicated, as I mentioned up front, to really establishing new standards-of-care in areas and putting investments in R&D on both the innovation side, so new products, and continuing that. In fact, we've got seven new products coming out over the next two years, combining that with exceptional clinical evidence to demonstrate why our products work incredibly well. And then also putting efforts around our sales team and teams out in the field to specifically be the best in the world at understanding our products and understanding how they help patient care on that front. And we think that we're really well positioned across all of our product lines on that and welcome the competition and also welcome the validation of the markets that we're in.

Robbie Marcus

Analyst

Appreciate it. Thanks a lot.

Operator

Operator

Thank you. Our next question comes from the line of Danielle Antalffy with UBS. Your line is now open. Danielle, your line is open. Please check your mute button.

Simon Negin

Analyst · UBS. Your line is now open. Danielle, your line is open. Please check your mute button.

Hey, everyone. Can you hear me? This is Simon on for Danielle.

Angela Wirick

Management

We can hear you.

Michael Carrel

Management

We can hear you, Simon.

Simon Negin

Analyst · UBS. Your line is now open. Danielle, your line is open. Please check your mute button.

Hey, guys. Thanks for taking the question. This is Simon Negin. Your Cryo segment really demonstrated great growth over the past several years, but it's naturally moderated just given the scale. Do you think mid-teens' growth in the segment is sustainable? And what are the puts and takes to really think about moving forward here?

Michael Carrel

Management

Yeah. I appreciate the question. You stated it very well. It's obviously gotten to the size and scale of $50 million business that grew 26% this year. We do think that those mid-teen-plus growth rates are absolutely sustainable, not only in thoracic. So, if you look at just the thoracic market, we're less than 20% penetrated today. So we have a long way to go. And as I mentioned in my comments, we're investing in clinical evidence to demonstrate both the economic and clinical value around that to hopefully push those numbers up even more over the coming years. You top that off with us investing in, much like I talked about all of our product lines, we've got the cryoSPHERE Plus that just came out this year. We've got a new product coming out later on this year that is an advancement on top of that, that are hopefully going to reduce the time that they need to actually do their ablation, which hopefully will also open up the sternotomy market a little more aggressively than it has because that's been a pushback in that market. So, thoracotomies alone, less than 20% penetrated. We're coming out with new products that reduce time that'll hopefully enable and actually get us into the sternotomy market a little bit more aggressively as you look in future years. And so, we feel like we're in a really good position relative to the growth there. And the final thing I'll add is when we talked about, or you heard it in my comments as well, there are other areas, extremities in particular, that could also benefit from the Cryo ablation that we use. And we're in the process of actually looking at that, evaluating it, and studying it. We're not ready to announce anything yet, but over the next couple of years, I do believe that we'll be announcing getting into other areas outside of just thoracic and sternotomy, which have a lot of room for growth already. So, that's a good way -- that's a long way of answering, yes, we feel comfortable with the kind of mid-teens growth, being in that range for a long time.

Simon Negin

Analyst · UBS. Your line is now open. Danielle, your line is open. Please check your mute button.

That's really helpful. Thank you guys. One quick one for you. You mentioned potentially launching a product in the IST segments this year. Is that still on target? And any details on that would be incredibly helpful.

Michael Carrel

Management

Yeah. So, a reminder for people, because we didn't really go into detail on today's call, we're running a trial called HEAL-IST for patients with inappropriate sinus tachycardia. What that represents are people that have elevated heart rates while they're resting, typically above 90 consistently. Most of these patients are in the mid-100s, and it tends to affect women kind of in their 20s to 40s or so. It's a very large patient population, well over a million patients that actually represent this market. There were some, an EP and a surgeon out of Belgium kind of invented a procedure in which you could leverage using our technology in combination with the mapping and the work done by the electrophysiologist to basically reduce that. And they showed almost 100% improvement at both a six-month and one-year timeframe after the procedure. The existing products that we have work incredibly well. It's under investigation for this particular disease in the United States right now, and we're making great progress on enrollment there. And yes, we are developing a new product, because right now our product today works incredibly well, but it takes a little while to actually get access to what you need to do there. And so the new product is custom-built very specifically for IST and for this specific surgery. And we do anticipate late this year, early next year to kind of have that product on the market.

Simon Negin

Analyst · UBS. Your line is now open. Danielle, your line is open. Please check your mute button.

Thanks so much.

Operator

Operator

Thank you. Our next question comes from the line of Bill Plovanic with Canaccord. Your line is now open.

Unidentified Analyst

Analyst · Canaccord. Your line is now open.

Hi, Mike and Angie. It's John on for Bill tonight. Thanks for taking our questions. And congrats on a strong Q4 too. Maybe just starting on EnCompass. You said about 50% of U.S. revenues is from the clamp now. Can you talk about what hurdles still exist, the remaining users, the shifts, the new device? Is this just contract timing or price sensitivity? And do you plan on eventually stop selling the older versions of the clamp? Thanks.

Michael Carrel

Management

Yeah. I'll start with the last. We don't anticipate stopping selling any of our old clamps. They're actually exceptional. We continue to get really good feedback on that. They work incredibly well. They're really geared towards specific surgeons who are doing the full Cox-Maze for. They're the ones that we studied under PMA. For EnCompass, quite frankly, it's just going to take time to educate people how to use the product, get people comfortable with that. We're expanding into new sites. We're in about 55% to 60% of the sites in the U.S., so we've got a lot of room for growth relative to that. We're also planning to do a clinical trial as well, very specifically, much like we did for the ABLATE trial, which was what got us the PMA approval for our original clamps. We will anticipate doing that. We think that with that additional clinical evidence, that could also have an impact on adoption over time. This isn't one of those ones that is just going to grow overnight, but it's accelerated our growth rate. If you would have asked, I think, anybody if our open business could grow kind of above the low double-digits, kind of the 9%, 10%, 11% that we were growing for many, many years, this combined with reimbursement changes that have happened over the last couple of years have really accelerated adoption and more ablations that have happened. So, I think I feel really good about the progress. It's much better than we ever expected. And we'll continue to kind of talk about it out in the field from that standpoint.

Unidentified Analyst

Analyst · Canaccord. Your line is now open.

Great. Thanks, Mike. And then just on pain management, too, to circle back to some of the other comments. How should we think about the timing of the economic outcome data that you've mentioned? Is that going to move the needle in 2024 or beyond? Are you still considering gathering data to support an opioid reduction label? Thanks.

Michael Carrel

Management

Yeah. I don't know that I would say that it's going to be a 2024 event relative to that data. It's going to be a cumulative aspect of the data for Cryo Nerve Block and not one definitive trial. We're actually supporting many trials that are multi-center across the country and over in Europe. The purpose of that is that the totality of all that evidence, we think, is what's going to actually change practice. That's going to take several years to do it, but I think more and more papers are coming out every year. We had 14 trials that we were supporting or so last year. That number is going to continue into this year. Many of those are looking at opioid reduction as part of what they're looking at overall as the outcome. And so, I do believe that that is something that's very important for people to track and to know. And I think more and more papers are going to be written about the fact that people that do use this product tend to have a lower use of opioids once they leave the hospital.

Unidentified Analyst

Analyst · Canaccord. Your line is now open.

Great. Thanks again.

Operator

Operator

Thank you. Our next question comes from the line of Matthew O’Brien with Piper Sandler. Your line is now open. Matthew O’Brien: Afternoon. Thanks for taking that question. So, I don't know if this is for Mike or Angie, but I think Angie mentioned that you're factoring in some competitive pressure here in '24 into your guide. You've grown 20% the last two years on the top line. You're guiding 16% of the midpoint, so about 400 basis points. That's around $16 million of -- I think of potential competition you're factoring in. I don't know if it's large numbers, whatever it may be. Is that the right way to characterize the amount of pressure that you're anticipating? Is it only in the Clip business? Then if I do the math on it, it would seem like you're incorporating in around 10%, maybe a little bit north of that share loss. Is that the right way to characterize it?

Angela Wirick

Management

Yeah. Matt. I think you know based on years here that we start the year and we want to make sure that we're putting out a guide that we feel really good about executing against and gives us -- positions as well to kind of beat and raise as we go throughout the year. The range does consider both the growth drivers in our business as well as the potential competition in our market. but I think to that point, we are working in markets that are very, very underpenetrated and that we believe that there's still significant growth potential even with competitive pressure. So, long-winded way of saying it's not 10 points of or that kind of loss relative to Medtronic share. More importantly, I think what informed our guide through 2024 is just the strength of our portfolio and the momentum that we're seeing as we exit 2023 and start a new year in 2024. But we want to make sure that we guide to numbers that we can execute strongly against. That's been our philosophy for years and continues to be as we start the New Year. Matthew O’Brien: Okay. And Angie, specifically, I know there's a lot of trialing going on. Have you seen people flipping over to [indiscernible] and using it a lot more cases, or are you still seeing a dynamic where they maybe trial it and they just say, you know what, I don't like this for the most part. I'm sure there's some people that'll flip, but what are you seeing specifically there? And I do have one more follow-up.

Michael Carrel

Management

I mean, we're definitely seeing people trial it across the country, but we feel really good about the strength of our franchise out there, Matt, and feel like people really love the AtriClip. It's set a very high bar in terms of how well it works. People understand that we have a tremendous amount of clinical evidence and data behind it. Matthew O’Brien: Order basis, so just curious what you're seeing there in terms of adoption, expectations for growth there. Is it still another mid-teens? I don't know if the guidelines can help a little bit as well. And then just any thoughts on competition? I know there's somebody that's filed to compete with you. Is that something that you're building in a little bit this year, or something that potentially could impact that business as we head into '25? Thanks.

Michael Carrel

Management

As Angie mentioned on the guidance, pretty much all of our businesses we think being around that 15% to 17%. I mean, pun intended, they're all converging around that particular area. And so, we feel like -- obviously there's upside potential in every one of our businesses, to your point, Matt. We're seeing great growth there. I think that to be able to continue to grow on the kind of baseline numbers that we've got at that kind of rate in cardiac surgery the way we are, we feel really good about it. But we anticipate that being kind of in that 15% to 17%. Pretty much all of our franchises across that from that standpoint. And we're always looking at competition. I mean, there's nothing specific to comment on at this point. And if competition does come in, I think that we will obviously address it. But we feel really comfortable with the guidance that we've given. And that -- as Angie mentioned, we try to take a really conservative look at it at the beginning of the year to ensure that we can make sure that we can meet and beat it throughout the year. Matthew O’Brien: Thank you.

Operator

Operator

Thank you. Our next question comes from the line of Marie Thibault with BTIG. Your line is now open.

Sam Eiber

Analyst · BTIG. Your line is now open.

Hey, Mike. Hey, Angie. You've got Sam Eiber from Marie. Thanks for taking the questions and congrats on a nice finish to the year. Maybe I can start on CONVERGE and just looking at the U.S. business growing for the MIS business growing 16% sequentially, 30% year-over-year. It does sound like things are really starting to click there. And I know you addressed some of it in your prepared remarks. But any more color you can give on any specifics and maybe does that give you the confidence now to push a little bit harder on new site activation this year?

Angela Wirick

Management

Yes, Sam. I think we feel really good about the activity in the fourth quarter. I think this is reflective of a year plus of our team in the field, supported by many others in the business really trying to hone in on where programs had a really good interest in starting a CONVERGE program, why they've not been able to accelerate and see the kind of growth that we would expect. So, we feel really good that the activities are paying off and that we're making a difference in the accounts that we're focusing in on. I'd say longer term when you think through 2024, we're looking for that to be more broadly replicated throughout the base of accounts so that we can continue these kinds of growth rates. But I'd say the efforts in the field are really what we're seeing is starting to pay off and looking for that to have a broader impact in 2024.

Sam Eiber

Analyst · BTIG. Your line is now open.

Okay.

Angela Wirick

Management

And it's relative -- I think the second part of your question was new account activations. We did see a couple of new account activations in 2023. I'd say the focus of our team at this point in time is on existing accounts. I think as they operate throughout 2024, there's still a lot of interest from customers. There still were very under penetrated in terms of the universe of accounts that could have CONVERGE procedures or CONVERGE programs and are still training new accounts. And I think the work that we're doing today to help existing accounts be more efficient and think about building their programs, I think long-term will help us initiate new accounts and have them scale quickly.

Sam Eiber

Analyst · BTIG. Your line is now open.

Really helpful, Angie. Thanks for the added color there. Maybe just flipping to AtriClip and maybe looking beyond maybe some of the competitive dynamics. But you also mentioned some guideline changes. And I'm just wondering if that can be maybe an additional tailwind to the underlying market and adoption for the Clip business. Thanks for taking the questions.

Michael Carrel

Management

Yeah. Absolutely. We think that the guidelines are pretty monumental for the entire space. And it's basically saying a Class 1A recommendation is basically saying you should treat this appendage every single time somebody has atrial fibrillation today. And that is not just the cardiac surgeons doing it, but it's ACC and AHA to the referring cardiology community is basically saying everybody needs to treat the appendage when they're undergoing cardiac surgery. And so absolutely, we think that's a really good sign for this market overall. And obviously, AtriClip is being used to manage the appendage by many people around the globe. So it's a great validation, just like competition is a great validation of the space and what we're doing there. And then obviously, we're expanding that market with LeAAPS so that eventually the data we get with that changes the guidelines for every patient, not just those that have Afib. That's our goal with that. That's why we're investigating it. And you can see the excitement with 1,700 patients already enrolled out of a 6,500-person trial. It's pretty remarkable to see that kind of growth. That's the excitement people have and the belief in managing the appendage.

Sam Eiber

Analyst · BTIG. Your line is now open.

Well understood. Thanks again for taking the questions.

Operator

Operator

Thank you. Our next question comes from the line of Joseph Conway with Needham. Your line is now open.

Joseph Conway

Analyst · Needham. Your line is now open.

Hi, Mike. Hi, Angie. It's Joseph on for Mike. I guess maybe just touching on gross margin improvement in the quarter, I think Angie called out some production efficiencies. And looking into 2024, I think in the comments, you guys talked about just being in line for 2024, potential modest improvement. I was just wondering if you could maybe give some more color around what happened in this quarter and some of those cost-saving initiatives that you expect to rollout this year, how you expect that to be phased.

Angela Wirick

Management

Yeah. So, what you saw in the fourth quarter, really strong, I'd say, production efficiencies offsetting. We had quite a few headwinds coming from the mix of our international business. That led to an improvement off of 2020, 2022, the fourth quarter comp. And as we enter into 2024, I'd say kind of more of the same. You're going to see nice improvements. If only thing that we saw was improvements to kind of production efficiencies with the same kind of mix of revenue, you'd see some nice improvements in 2024. But we are expecting some headwinds given the mix anticipation in 2024. We've talked about in the past a couple of areas where we expect to see some improvements to margin. The first would be with the launch of cryoSPHERE Plus probe to the extent that the adoption of that probe takes off in comparison or replaces our existing cryoSPHERE probe. There is a nice benefit to our gross margin. Again, our launch is anticipated in the second quarter. So you would see more of that benefit in the second half of the year. And then the other thing we've talked about on other calls is the EnCompass clamp. Our operations team and engineering team did really nice work throughout 2023 to say, given the demand that we're seeing in this particular product line, what are some ways that we can produce this product better and more efficiently. They also have come with some cost-savings that we would anticipate later in 2024. So I think the big driver in 2024 when you think about gross margin is primarily mix, but knowing that there's some fundamental production efficiencies and some nice things happening within our operations that help be a tailwind to the overall number.

Joseph Conway

Analyst · Needham. Your line is now open.

Okay. Thank you. That's very helpful. And then I guess just a quick one on the new AtriClip product. You gave some commentary around timing for the launch, but just maybe if you could talk about pricing, what you guys are thinking about that, especially with Medtronic coming into the market, if there's anything that you're trying to hold back, any price increases for that?

Michael Carrel

Management

Yeah. So, first, I'll comment on the product. It's called the FLEX Mini. We did file for a 510(k) and we feel like this product is going to be incredibly well-received. It's about a third of the profile and size of our product, our FlexV product on the market today. It's incredibly easy to deploy. All the testing that we've seen so far is that it is going to be by far and away the most superior product on the market going forward. We have not determined our pricing strategy at this point. And so we'll probably hold back in terms of discussing that in any kind of detail, but we're evaluating what the best pricing strategy is right now.

Joseph Conway

Analyst · Needham. Your line is now open.

Okay. Great. Thanks so much and congrats on a great quarter.

Michael Carrel

Management

Thanks.

Operator

Operator

Thank you. Our next question comes from the line of Danny Stauder with Citizens JMP. Your line is now open.

Daniel Stauder

Analyst · Citizens JMP. Your line is now open.

Great. Thanks. Can you hear me?

Angela Wirick

Management

We can hear you.

Daniel Stauder

Analyst · Citizens JMP. Your line is now open.

Great. So, first off, I just wanted to ask broadly about procedure volumes. So I've just -- we've heard from some of your peers commenting on elevated volume levels and just wanted to get your color on that and particularly as it relates to the open surgical market. Have you seen any notable change in valve or cabbage procedures that have led to some of the growth in open ablation and your open AtriClip procedures? Thanks.

Michael Carrel

Management

Yeah. I don't know that we've seen any kind of dramatic improvement. There's been steady improvement since COVID, but I think we're in a good normalized period now where typically you'll see cardiac surgery going in that kind of 1% to 2% per year. And I don't think we've seen anything different than that over the course of the last year or so. I've heard different reports that that might change and you might start to see some improved growth across the procedure in 2024 from some places. I know HCA talked about it on one of their calls on in terms of their cardiac surgery volumes. I don't know that I've heard that across every single system. So I guess -- I'd say right now I'm cautiously optimistic on that one.

Daniel Stauder

Analyst · Citizens JMP. Your line is now open.

Great. Thank you. And then this one follow-up, turn to appendage management. The growth in MIS ablation was great to see, but with that, are you seeing an uptick in your AtriClip minimally invasive procedures? And then could you remind us where that AtriClip mix has opened to MIS today and how has that changed over the past year or so, and where you think that could go in 2024? Thank you.

Angela Wirick

Management

Yeah. That was a nice byproduct of the strength of our MIS business in the fourth quarter. We saw an uptick in our MIS appendage management, the AtriClip Pro products, realizing pretty equal growth to the open AtriClip products leading to about 22% growth to the fourth quarter in the U.S. And our attachment rates, we continue to see a steady increase in attachment a year or so ago. We were talking about around a 75% attachment to our CONVERGE procedure and now we're, I'd say, kind of mid-80s at this point in time and continue to receive really good, strong feedback from accounts that are starting CONVERGE programs or have adopted CONVERGE programs, the interest in treating the appendage surgically during the CONVERGE procedure. As we exited the year, when you look at our U.S. appendage management business, about 25% of the revenue was from our MIS AtriClip business and about 75% of the revenue was in our open Clip business and I think, given the strength of both of those franchises, our open and MIS ablation businesses would expect for that next to remain relatively similar with the potential for upside, I think, for the MIS product.

Daniel Stauder

Analyst · Citizens JMP. Your line is now open.

Great. Thank you very much.

Operator

Operator

Thank you. Our next question comes from the line of Suraj Kalia with Oppenheimer & Company. Your line is now open.

Suraj Kalia

Analyst · Oppenheimer & Company. Your line is now open.

Hi, Angie, Mike. Can you hear me all right?

Angela Wirick

Management

We can hear you.

Suraj Kalia

Analyst · Oppenheimer & Company. Your line is now open.

Perfect. Hey, Mike. So, a couple of esoteric questions. I was wondering if you could help us out. AtriClip, in general, is it on consignment or should we think about inventory also? And more specifically, as you'll enter FY '24, just given all the dynamics and your prepared remarks, how should we think about the pricing flow through that you'll think about for FY '24?

Michael Carrel

Management

Yeah. On the consignment, we don't really have any consignment product. That's not typically it's -- we're very much on kind of a use and then replace. So, we keep very, very little inventory whatsoever at sites, just enough for them to kind of plan out the procedures in the upcoming week or two. But we do not have a lot of inventory on shelf. That's actually purposeful. We want to understand the demand. And we've got great inventory here to be able to supply that on a real time basis. We've got 99.8% kind of delivery to make sure that no patient is not being treated from that standpoint. Related to price, we feel like we've got a really good pricing strategy today. We've obviously got a product on the market. Our initial one, our original AtriClip, kind of the kind of first three generations of the product are out there today. Those are priced at a lower level. The FlexV, which was our premium product today, is also in the market. Our highest priced product of the minimally invasive products above that. So I think we're in a really good position relative to pricing today. And we don't have any specific things to change anything on that front in the near future.

Suraj Kalia

Analyst · Oppenheimer & Company. Your line is now open.

Got it. Mike, in terms of AtriClip Mini, is this just a desire for product stratification? And what I'm looking at is in terms of complete isolation of the LAA, you're presumably going a smaller form factor. So just kind of walk us through the rationale for introducing Mini. And Mike, also remind us in terms of persistent AF, what percent of the cases being done by AtriCure today are persistent AF versus longstanding persistent AF? Thank you for taking my questions.

Michael Carrel

Management

Sure. On the FLEX Mini, we spend a lot of time, as we mentioned in our comments, we've had 500,000 implants to date. And we do a lot of work with our customers to figure out what improvements do they want to have to the product. And so the biggest thing was really, quite frankly, they wanted a smaller product, meaning that it's just a smaller profile overall. That's what the FLEX Mini does. It actually is about a third the profile of the other products. And that's the biggest benefit that people are going to get relative to using that. Also, as many of you may know, we've got a V-shaped product, and we also have a hoop-like product, which is the original product that we had on the market. The hoop-like product is the one that does not have as good of a deployment as the V-Clip product. And so many people wanted a hoop-like product that was smaller and had a very nice and easy and usable deployment tool with it as well. And so that was the primary feedback that we got from people. And that's effectively what the Mini brings to market. In addition to that, and probably as important, is that the Mini is also going to be used in our -- we have the ProV product for minimally invasive, and we will have a ProMini product as well that'll come out in late 2025, likely. And that product is going to be able to go through at least a seven millimeter, possibly a five millimeter trocar to make it even less invasive as somebody actually has to do the procedure from a minimally invasive perspective. So the product, by being so -- the profile being so small, it can go through those smaller trocars, and there's a big benefit on that. In terms of your second question, I guess, I believe you're probably talking about the CONVERGE area in terms of the distinction between persistent and longstanding persistent. Our label is for longstanding persistent. That's what we talk to. I'd say most of the patients fit within the longstanding persistent marketplace. Very few are persistent patients in terms of what we're seeing. Most of the patients that we see are patients that have had failed catheter ablations, one, two, or three failed catheter ablations before they then go to a CONVERGENT or a Hybrid type procedure. And so, I believe that might be what you're referring to, and hopefully I answered that question.

Suraj Kalia

Analyst · Oppenheimer & Company. Your line is now open.

Fair enough. Thank you.

Operator

Operator

Thank you. This concludes the question-and-answer session. I'd now like to hand the call back over to Mike Carrel, CEO, for closing remarks. End of Q&A:

Michael Carrel

Management

Great. Again, everybody thank you for joining us today, and we look forward to having a great 2024 together. Have a good one. Bye now.

Operator

Operator

This concludes today's conference call. Thank you for your participation. You may now disconnect.