Boston Scientific (BSX) Q1 2026 earnings call transcript

Thank you, Bailey, and thanks to everyone for joining us. With me today are Mike Mahoney, Chairman and Chief Executive Officer, John Monson, Executive Vice President and Chief Financial Officer. During the Q&A session, Mike and John will be joined by our Chief Medical Officer, Dr. Ken Stein. We issued a press release earlier this morning announcing our Q1-2026 results, which included reconciliations of the non-GAAP measures used in this release. The release, as well as reconciliations of non-GAAP measures used in today's call, can be found on the investor relations section of the website. Please note that on the call, operational revenue excludes the impact of foreign currency fluctuations, and organic revenue further excludes certain acquisitions and divestitures for which there is less than a full period of comparable net sales.

Guidance excludes the previously announced agreement to acquire Penumbra, which is expected to close in 2026, subject to customary closing conditions. For more information, please refer to the Q1 financial and operating highlight stack, which may be found in the investor relations section of our website. On this call, all references to sales and revenue are organic, and relative growth is compared to the same quarter and prior year, unless otherwise specified. This call contains forward-looking statements regarding, among other things, are financial performance, business plans, and product performance and development.

These statements are based on our current beliefs, using information available to us as of today's dates, and are not intended to be guarantees of future events or performance. If our underlying assumptions turn out to be incorrect or certain risks or uncertainties materialize, actual results could vary materially from those projected by the forward-looking statement. Factors that may cause such differences are discussed in our periodic reports and other filings with the SEC, including the risk factors section of our most recent annual report on Form 10-K. Boston Scientific disclaims any intention or obligation to update these forward-looking statements except as required by law. In addition, this call does not constitute an offer to sell or the solicitation of any offer to buy any securities or solicitation of any vote or approval in connection with a proposed transaction with Penumbra.

Boston Scientific has filed this SEC, a registration statement on Form S-4 containing a process statement of Penumbra and a prospectus of Boston Scientific that contains important information about Penumbra, Boston Scientific, the proposed transactions, and related matters. At this point, I'll turn it over to Mike.

Thanks, Lauren, and thank you to everyone for joining us today. First quarter represented a solid quarter for Boston Scientific with total company organic sales growth of 9.4% versus our guidance range of 8.5% to 10%. The first quarter adjusted EPS of $0.80 grew 6%, achieving a high-end-over guidance range of $0.78 to $0.80. And Q1 adjusted operating margin was 28%.

Turning to our outlook, 2026 has proven to be a more challenging year than we initially expected. And to that end, we are guiding into organic growth of 5% to 7% for second quarter and reducing our full-year guidance to 6.5% to 8%, reflecting unanticipated headwinds and changing business patterns that I'll cover in more detail on this call. Our second quarter 26 adjusted EPS guide is 82 to 84 cents, and we now expect our full year adjusted EPS to be 334 to 341, representing growth of 9 to 11%. I and our company does not take this change lightly, as I and Boston Scientific trade with great pride in ourselves and consistently executing against the guidance and goals we provide.

Importantly, we remain convicted in the future of Boston Scientific. We have a strong global team committed to high performance, and we continue to invest in key new and existing markets, which we believe will enable us to deliver in our fundamental goal of driving differentiated performance over the LRP. I'll now provide some additional highlights of our first quarter, along with some comments on our outlook.

Regionally and on an operational basis, the U. S. grew 11%, with double-digit growth in five out of our eight business units. Europe and Middle East Africa grew 1% operationally. Growth in the quarter was driven by Ferrapulse, coronary and vascular therapies, and Neuromod, offset by the discontinuation of Acura and PolarX, largely impacting the Amir region. Last year, we did announce our intent to discontinue the PolarX cryocatheter, but have accelerated that timing given some recent safety events and the availability of non-thermal ablation technology.

As we look forward, we expect that growth in demand will continue to improve with the annualization of the accurate discontinuation in 2Q and ongoing momentum from Farapulse, Watchmen, and other Q products.

AsiaPAC delivered a strong quarter and grew 12% operationally, led by double-digit growth in a number of countries, including Japan and China. First quarter growth in Japan was led by our differentiated PFA ecosystem with Opal, Fairview, and Farapulse, as well as strong reception of Watchman Flex Pro. Within the quarter, we're pleased to have received PMDA approval for the de novo indication of our coronary dry-coded blue agent DCB, expanding the patient population eligible for this differentiated technology.

China also delivered strong growth, inclusive of the impact on the BVP, led by our interventional cardiology portfolio, particularly our imaging technologies. We are making consistent progress against our varipose goals in a competitive market in China and received NMPA approval within the quarter for Opal HDX mapping system with Fairview, further building out the PFA platform. Now some commentary on our business units. I'll start with Urology. Urology did have a difficult quarter in Q1 as sales grew 1% organically, falling short of our expectations driven primarily by the Stone management and sacral neuromodulation businesses.

Within Stone, underperformance is driven by China VBP, as well as some key product gaps in the core Stone portfolio. We expect the recent FDA approval for insurers to unlock value within our StoneSmart ecosystem alongside LithuView Elite. And we also anticipate launching additional new products in 2026, including a slim ureidoscope later this year.

Our sacral neuromodulation business continues to see impact on commercial model disruption. And importantly, within first quarter, we have hired and trained a significant number of new sales and clinical reps. We do anticipate improvement in this pelvic health franchise throughout the year as the S&M commercial organization capabilities stabilize, along with the addition of e-coined tibial nerve stem with the closure of Valencia Technologies in April.

We expect our urology performance to improve throughout the year. However, we now expect our full-year euro growth to be low to mid-single digits in 2026. Endoscopy sales grew 7% organically, with strong results across the business and better than anticipated performance from Axios as we were able to ramp supply and available product sizes. As we look to the second quarter, we will continue to see some impact from Axios while also navigating other transient supply chain disruptions in endoscopy. Importantly, we expect improvement in the second half of 2026 as the underlying business is very strong and we anticipate resolution of the supply chain issues.

Neuromodulation has a strong quarter with a granite sales growing 15%, with our comprehensive portfolio growing low double digits, excluding the impact of Malib. Our pain business grew mid-teens, inclusive of a strong quarter from Malib, as I mentioned, which closed at the end of January. Intracept continues to perform well, supported by compelling FIGER data demonstrating the long-term efficacy and cost-effectiveness of this treatment for chronic low back pain. In DBS, we saw continued adoption of the Cartesia X leads and accelerating uptake of the Illumina 3D programming algorithm in the U. S. Cardiovascular-delivered organic sales growth of 11%. Within those businesses, we'll start with ICDT. Interventional cardiology vascular therapies grew organic sales 8%. This business grew 9% organically, driven by double-digit growth in our coronary therapies franchise with strength in agent and ongoing momentum with our imaging portfolio.

And earlier this year, we completed enrollment in our fracture trial, studying the seismic IVL device in coronary arteries with data to be presented at EuroPCR on May 19th. We continue to expect launch in the U. S. in the first half of 27. Our vascular therapies business had a nice quarter, growing 7% organically, driven by double-digit growth in TCAR and Verifena. and this is offset by large VDP impact on their arterial business in China, which is expected to annualize in second quarter.

We expanded our launch with our seismic peripheral IVL for above the knee with positive physician feedback on performance. We expect to ramp our manufacturing supply chain over the course of the year and continue to anticipate launching our below the knee indication in the second half. In first quarter, positive data from HyPytho was presented at ECC evaluating ECOS plus anticoagulation versus anticoagulation alone, providing new clinical evidence that can help physicians make more informed treatment decisions for patients with acute pulmonary embolism.

We remain excited about the opportunity to add the Penumber team and highly differentiated portfolios at Boston Scientific. We anticipate that the deal will close on the 2nd after 26th, subject to the Penumber shelter vote on May 6th and the receipt of the remaining regulatory clearances. Our interventional oncology business had a nice quarter with organic sales drawing 15%, driven by our broad offering of cancer therapy technologies.

Within the quarter, we received FDA clearance of any day dosing and initiated a limited market release. Any day dosing is enabled by the Therisphere 360 Y90 management platform, allowing physicians to schedule treatments on more days of the week and offering more streamlined ordering and operational efficiencies. Cardiac Rhythm Management sales declined 3% in the quarter.

Our low-voltage business saw some impact in the quarter as we navigated our physician advisory and came up against a tough comp within our first quarter 2025 changeouts. On the high-voltage side, we saw some impact on the Middle East conflict impacting this particular business. In the first quarter, our diagnostic franchise grew low-level digits with continued strength across our broad diagnostic portfolio. And overall, we anticipate that our CRM business will return to growth in the second quarter and expect a little single-digit growth of the year, supported by our full launch of the Allup grow in the second quarter within the U. S. Turning to Watchman, Watchman grew 19% organically in the first quarter, which was below our expectations, with pressure on volumes in the U. S. as the quarter progressed.

We believe this reflects the annualization of the initial concomitant adoption tailwind and a softening in standalone watchman cases driven by hospital capacity, related procedure prioritization, and evolving reimbursement dynamics. Importantly, we remain focused on expanding physician and patient education within the approximately 5 million patient-indicated population today. We expect data from CHAMPION to support a return to 20% market growth over the LRP.

In late March, CHAMPION data was presented as a late-breaker at ECC with the trial achieving all primary and secondary endpoints, reinforcing the safety and efficacy of Watchmen, and highlighting the high burden of clinically relevant bleeding on oral anticoagulation. As a next step, in addition to submitting for a label update, we are working with medical societies to support consideration of changes to LAAT guidelines using the totality of Watchmen clinical evidence ahead of any update to the National Coverage determination. We also have additional data being presented to HRS this weekend, a champion post-ablation analysis, which will provide further insights on this patient population.

Across the globe, the results from champion provide important evidence to support the expansion of the patient population eligible for watchmen over time at large markets, including the U. S. , Japan, China, and Europe. For full year 26, we now expect global watchmen growth to be mid-teens, with low-to-mid-teens in the U. S. In the U. S. , while concomitant demand continues to strengthen, we anticipate overall Watchman growth to decelerate with tougher comps and expect standalone Watchman procedures to improve over the course of the year as it takes time for the totality of this clinical evidence to translate into clinical practice. We remain very confident in a long-term outlook of the business supported by great clinical evidence, market development, and new product innovation.

Turning to EP, organic sales grew 22%, 18% in the U. S. , and 30% internationally. International growth was driven by our innovative portfolio, including our expanded opal mapping footprint and catheter utilization, with strong double-digit PFA growth in Europe, in a highly competitive environment supported by the launch of Fairpoint. U. S. growth was driven by continued expansion of opal, strong catheter utilization, and Fairpoint. our PFA focal point catheter, which is performing ahead of our expectations and has moved into full launch Looking ahead we now expect a global EP business to grow approximately 10 in 2026 And within the U we are updating our full expected growth to be in the mid-single-digit range, with continued strength internationally at plus 20%, inclusive of a full-year impact of approximately $35 million from the discontinuation of PolarX.

This outlook is a change from previous commentary, but we feel it's prudent and reflects ongoing competitive dynamics offset by strength in our evolving Ferrapulse PFA catheter and mapping portfolio.

We are highly confident in our ability to maintain our leadership position in PFA, both in the U. S. and internationally, through investment in commercial capabilities, ongoing clinical evidence, our expanding mapping footprint, and an impressive next-generation catheter launches, including our Fair Wave Ultra in the first half of 27. And this weekend, avant-garde, we're studying feripulse, a new patient population of drug-naive persistent AF patients, will be presented as a late breaker at HRS.

Additionally, we will see data from our first in-human Elevate PS study studying Feriplex, which is our large focal map in the blade catheter for more complex arrhythmias. We anticipate initiating in our IDE later this year and continue to expect launching Fairflex in the U. S. in 2028.

So in closing, I'd like to share again my confidence in our team and the future of Boston Scientific. While this year has proven to be more challenging than we anticipated, we believe Boston Scientific is competing in the right markets. With a wander of approximately 8%, we continue to be uniquely positioned to drive differentiated top-line growth. We will continue to do this through strategic internal innovation, clinical evidence, external VC and M&A investments, along with a disciplined approach to expanding operating margins, all of which have resulted in our track record of delivering double-digit adjusted EPS growth. I'm very grateful to our talented team of global employees who work every day to advance science for life and have confidence in the sustainability of our top-tier financial performance.

With that, I'll hand it over to John.

Thanks, Mike. First quarter consolidated revenue of $5,203,000,000 represents 11.6% reported growth versus first quarter 2025 and includes a 220 basis point tailwind from foreign exchange, which was in line with our expectations. Excluding this $104 million foreign exchange tailwind, operational revenue growth was 9.4% in the quarter. Organic revenue growth was also 9.4%, in line with our first quarter guidance range of 8.5% to 10%. C1-2026 adjusted earnings per share of $0.80 grew 6% versus 2025, achieving the high end of our guidance range of $0.78 to $0.80.

Results include an approximate $0.01 headwind from FX. Adjusted gross margin for the first quarter was 70.5%, which represents a 100 basis point decline versus the first quarter of 2025, primarily driven by tariffs as well as inventory charges related to the discontinuation of our Polarex cryoagulation system. We now expect full year 2026 adjusted gross margin to be slightly below full year 2025, largely driven by lower than expected product mix benefit and incremental investments in our global supply chain and quality systems. First quarter adjusted operating margin was 28.0%. We continue to expect full year 2026 adjusted operating margin expansion of 50 to 75 basis points, driven by OpEx leverage as we drive strong spend controls and continue to implement efficiency initiatives and optimize our organizational structure.

On a gap basis, first quarter operating margin was 21.2%. percent. Moving to below the line, first quarter adjusted interest and other expenses totaled $112 million in line with expectations, and our adjusted tax rate for the first quarter was 11.7%, which was in line with expectations and includes a benefit from stock compensation accounting.

Fully diluted, weighted average shares outstanding ended at $1,495,000,000 shares in the first quarter, and free cash flow for the first quarter was $170 million with $348 million from operating activities, less $177 million in net capital expenditures. We now expect full-year 2026 free cash flow to be approximately $4 billion. As of March 31, 2026, we had cash on hand of $1,453 million, and our gross debt leverage ratio was 1.8 times. Our top capital allocation priority remains strategic tuck in M&A, followed by share repurchase. In alignment with this strategy, we recently closed the acquisition of Valencia Technologies, which complements our urology business, and we expect our announced acquisition of Penumbra to close in the second half of 2026.

In addition, as previously disclosed, our Board of Directors recently approved an additional $4 billion under our existing share repurchase program, bringing our total authorization to $5 billion. While we have been restricted from being in the market, we intend to repurchase approximately $2 billion of our shares during the second quarter, subject to market conditions and applicable securities laws.

I'll now walk through guidance for Q2 in full year 2026. We now expect full year 2026 reported revenue growth to be in a range of 7.0% to 8.5% versus 2025, excluding an approximate 50 basis point tailwind from foreign exchange based on current rates. We expect full year 2026 operational and organic growth to be in a range of 6.5% to 8.0%. We expect second quarter 2026 reported revenue growth to be in a range of 5.5% to 7.5% versus second quarter 2025, excluding an approximate 50 basis point tailwind from foreign exchange based on current rates. We expect second quarter 2026 operational and organic growth to be in a range of 5.0% to 7.0%.

We continue to expect full year 2026 adjusted below the line expense to be approximately $440 million. And under current legislation, including enacted laws and issued guidance, we now expect a full year 2026 adjusted tax rate of approximately 12.0%. We now expect full year 2026 adjusted earnings per share to be in a range of $3.34 to $3.41, cents, representing growth of 9% to 11% versus 2025, including an approximate 4-cent headwind from foreign exchange.

We expect second quarter adjusted earnings per share to be in a range of 82 cents to 84 cents. In closing, we recognize that revising our guidance is a significant decision and not one that we made lightly. We believe our updated guidance appropriately reflects the unanticipated headwinds, and we remain highly focused on executing our full year 2026 guidance of 6.5% to 8% organic revenue growth, 50 to 75 basis points of adjusted operating margin expansion, and 9% to 11% adjusted earnings per share growth. For more information, please check our Investor Relations website for Q1 20.6 financial and operational highlights, which outlines more details on first quarter results and 2026 guidance.

And with that, I'll turn it back to Lauren, who will moderate the Q&A.

Thanks, John. Bailey, let's open it up for questions for the next 35 minutes or so. In order for us to take as many questions as possible, please limit yourself to one question. Bailey, please go ahead.

Yeah, thanks, Robbie. Good morning. I would say, you know, first quarter, we're overall pleased with that result, you know, the 9.4% growth and on track for our margin in EPS. You know, essentially what we saw, there's really three main contributors to the take down of the guide, which is not my happiest moment and very disappointed in that, as we're a company that consistently delivers on our commitments. So this is a guide down that we think are not proud of, but we think it's the right thing to do and best reflects the current environment and allows us to proper Putin guide to do.

But we can talk about the future of the company, but speak in a minute, but talk about the takedown. Particularly, it's really focused on the three areas, primarily EP, Watchmen, and urology. And if you start with Watchmen, we saw very, very excellent growth, as you know, in 2025. We grew almost 30%. We saw really strong, consistent volume trends in January. So there was no signal to any watchman weakness until we really saw the early days, kind of early to mid-February. We started to see declining watchman volume for the first time.

And as we did the analysis on that, we can talk more about it. Essentially, it is a strong increase in concomitant growth and a deceleration of standalone watchman. And I'm going to go through all those details now. That's the first primary one. So we see a declining Watchman trend growth throughout the first quarter. And therefore, in our guide, we think it's prudent to assume that in that guidance range. We can talk more about the rationale and reasons for that. The second primary reason is EP.

Our EP business had a very nice first quarter. We are absolutely confident that we will remain the PFA market leaders in the U. S. and globally in 26. and we have a very rich cadence. Just did an R&D review last week with the team. The launch is the next two and a half years. That's very impressive. But that indicates, even though the market's strong, we did lose a bit more share than we anticipated. So again, what we did in this guide anticipated greater share erosion than we're particularly seeing and still allows us to be the market share leader in PFA where we're guiding globally to approximately 10% NEP. And the last reason making up is urology, which I mentioned, that difficult quarter, first quarter.

You know, Neuromod had a real tough year a couple years ago, and that business is growing double digit. I'm not saying euro is going to return a double digit right away, but right now we're suffering in our core stone business and in the sacral nerve modulation area. We have very active execution plans in place to fix sacral nerve modulation, which we believe will be better as the quarters go on.

And then, of course, now we have some key product launches that will impact that business and help it quite a bit in 2027. But it's essentially going to be a below-market year in urology. So those are the three contributors overall to the guide down. Now, we're all done very objectively. We think it's prudent, and we think it's the best guide to provide to give shareholders confidence and to set up the business the right way. As you look forward in the LRP, we're not going to make a comment on the LRP top line growth at this point. We feel that will be under some slight pressure, clearly given the 2026 guide.

We will update that more in the future when we go through our strat plan process. We are comfortable with the 150 basis points of margin improvement in LRP, and we're comfortable with delivering WGPS growth to the LRP. And I guess lastly, that's the long answer I'm giving you, is we compete in an 8% WAMGAR market. We almost always grow at or above this WAMGAR. And this setup for 26 would show us at market at the high end of our guide or below that WAMGAR. This is not Boston Scientific. It's not what we do. And in 27, we have a number of key product launches. We'll have far easier comps than we do this year.

And we're very bullish about 27 and 28. We can detail that more. But sorry for the long response. Hopefully that helped a little bit.

I'll take a shot and join you and clean up if I'm a mess here. So we think second quarter is our toughest quarter of the year. We have a nice first quarter. For our second quarter, we have very challenging dollar sequential quarterly growth comps on a dollar basis, in particular with EP and Watchman. So that's our toughest quarter there. And so we also think with some of the impacts of some transient trends in endo and some other areas, that will be fixed for the second half of the year. So we think second quarter's our toughest quarter. That's the guide five to seven. And the full year guide, as you know, is six and a half to eight percent.

John, do you want to touch on any sequencing more?

Yeah, thanks, Joanne. So maybe stepping through Watchmen and EP. So you heard Mike mention in his prepared remarks, we expect global EP to grow mid-teens for the year. So that would imply, Joanne, low double-digit growth for the rest of the year for our global Watchmen business. So that's how you should think of Watchmen for the rest of the year.

Global EP at 10% for the year implies mid to high single-digit growth for the rest of the year. So if you then think of the rest of the business as mid-single-digit growth, that's about where we landed in the first quarter. Expect to see some acceleration there within urology, CRM to pick up.

So that's how you should expect the phasing as we go through the year. I'd say relatively consistent, slight uptick in the second half. They call it roughly 7% as we see euro and CRM drive better growth as we move through the year.

Yeah, I think John just gave some of those numbers. For EP, for the year, we expect global to be approximately 10%. In the U. S. particularly, we expect mid-single-digit growth for the U. S. business, which implies a flat 2Q to 4Q.

Flat to low single digit. And international about 20%. So call it flat to low single digit U. S. U. S. mid-single digit for the year.

Okay, and then so that's the story there. What's different about it from our previous commentaries where we said we were a grow hat market, we're disappointed. And we're disappointed to bring that guy's level down. but we think it's appropriate. We aim to be and we have high confidence that will maintain PFA leadership in the U. S. , internationally, globally, in 26 and throughout this LRP.

And we are very excited about the product launches that we have, in particular the three big ones coming up. 27 are third-generation Farifols, a differentiated ice platform, and we think a very disruptive Fariflex platform all in the next two and a half years. But today we are seeing increased competition. You know, there's three other large players in the marketplace.

We've made commentary before. Medtronic continues to be a solid competitor. J&J is enhancing their footprint in PFA. And Abbott is early stages of launch in the U. S. In Europe, we're really proud of our European performance where all three of those companies are performing. And we continue to grow at a 20% plus clip where we quite frankly have a quite advanced mapping capability and platform and doing very well there. So we do expect a little bit more share erosion than we've anticipated in the past and previous guides. But we think this is the perfect guide to do and allows us to continue that PFA market leadership while we're bringing that platform forward. And importantly, our mappers, which we've made a massive investment over the past two and a half years, continue to get stronger and stronger every quarter.

We continue to install more and more opal mapping platforms. Our mappers get more sophisticated, and we continue to add new catheters to the mix along with Ferroform, which we recently launched. So we'll continue to grow the mapping platform, continue to invest in that commercial capabilities. You'll see more direct investment in Watchmen in particular, so we'll invest both commercially in marketing and both our Watchmen and our EP businesses.

But we're confident we'll maintain PFA leadership, but we are going to see a bit more share than we anticipated earlier in the year.

Yeah, I'll ask Ken to add commentary here. You know, first on some of the factors, and first of all, we're very proud that, you know, we essentially created this category, leading in clinical science, created the concomitant category. And this category grew 30% last year, and we're expecting mid-teens growth this year. And we're seeing evolving practice patterns as this product continues to evolve with great clinical data and changing practice patterns.

So with that extraordinary growth in AF ablations and watchmen, we are seeing some practice pattern changes that I highlighted that we saw really become more acute in February. We're seeing terrific concomitant demand. bottom line, we are seeing pressure in kind of the stand-alone watchman implant business, which historically has not been a challenge for us. Those challenges with a stand-alone watchman area are a bit multifactorial. You're seeing a bit more switch to the EP from the interventional cardiologist.

The interventional cardiologist is less exposed to the concomitant procedure. They've got more structural procedures to do, and there's a bit of the reimbursement cut in that area. But you're seeing strengthening amongst the EP physician group. So those are some of the trends that have really moved it just recently, a bit more towards EP, a bit more towards concomitant, and less on standalone.

And our customers are also adapting to operational workflow. They're adding new labs. They're moving to ASEs because they've experienced multi-year growth of, call it 25% in Watchmen, multi-year growth of 20%, 25% in ablations. So there's a significant demand and pull, plus the approval of new structural heart procedures. So the hospitals themselves are investing in labs. Typically, concomitant, AFib are money winners for hospitals. So they're making the investments, but they're also moving through their own workflow challenges. We've seen a consistent backlog for Watchmen, which I guess is good, and high demand obviously for AFIN.

So on what are we doing to make it better, we're doing a lot right now to make it better. The most impactful thing quickly is commercial investments.

We are putting more focused commercial investments directly at the Watchmen business. Today we have a lot of strength because the same territory wrapped in many cases This is serving both the EP customer, EP, and Watchman, where we're going to augment them with additional focus on Watchman specifically and put a little more emphasis and focus directly at that interventional cardiology call point.

And we'll be making quite a bit of marketing investments to really highlight the outstanding data that we believe the first study of its kind that met its primary endpoints in champion that Kent can detail. So commercial investments, Medicare investments, marketing investments, position activation investments, all the leverage champion. It's also important to note that Ken can talk. Sorry, too much coffee.

Today, 25% of all watchman procedures are in common. We do expect that to grow to 50% over the LRP. So that view hasn't changed. What we've seen is an offset a bit in standalone watchman procedures. Ken, you want to talk more about Ken?

I don't have too much to add. But again, I think the first thing I'd say, in terms of questions, it just takes time to disseminate data and to educate physicians on the results of things like CHAMPION. And of course, we were not able to get out and pre-promote ahead of the data release and ahead of the publication in the New England Journal of Medicine. Having said that, the trial came. All of its primary safety and efficacy and endpoints and all of the important secondary endpoints, we do still anticipate that we will get a fake labeling, a fake guidelines, and eventually an updated national coverage determination. It just takes time for that to play through.

And then I think the other thing, just to reiterate what Mike said, in parallel with that, we see the opportunity continue to improve some of the operational efficiencies that are required just to unlock more operational capacity for handling these procedures. We see hospitals building out more labs dedicated to these procedures. The move of simple operations to ASC will further unlock capacity. and again just to highlight what Mike said, a very large opportunity for continued growth in concomitant procedures. And maybe the one statistic I'd add to what Mike said just to remind everyone, roughly 50% of patients for AFib in the U. S. today are done in patients who are at high risk of stroke, with a CHSBAC score of three or higher and who are potentially candidates for a common procedure.

Sure. Thank you for the question, David. The area that's not getting the spotlight on it is this ICBT, interventional cardiology vascular therapies group, which again has that one-timer of an accurate virtual anniversary, thankfully, in May, which will help that business. But that business is at extremely, very high level, driving the double-digit growth in China despite EVP, very global business.

Agents is continuing in our imaging businesses in particular, continue to exceed our internal expectations, which is terrific. And we're excited about the seismic launch that's really been in the small scale thus far within our purple vascular business. It's been very well received by physicians. And that fracture trial will read out at PCR in a month or so. And we expect to have that coronary approval as we enter 2027 And we focused right now on building up the manufacturing supply chain to enable a meaningful launch for seismic for both coronary and below and above applications in 2027.

So they also have a number of kind of singles, then doubles, key product launches in vascular to continue to widen that portfolio out. the interventional oncology business group mid-teams, and I talked about a key workflow launch that they additionally had, along with some second M&A that they're executing on. And hopefully the shareholder vote goes positive for us with Penumbra on May 7.

And we're really excited about that team, which is extremely talented and brings a really differentiated portfolio in gaps that we have across FOSTA Scientific in that category. So particularly in combination, you know, stand alone without Penumbra that business is doing extremely well in the future, ideally with Penumbra. That's a very unique, powerful growth driver for the company over this LRP period. And I think a lot of the discussion will still be on launch of MEP, but much more will pivot to that area given the launches in that area.

Lastly, I would just try to summarize med-surg. Overall, similar to EP, we have some challenges right now in urology. we're not happy with a 1% growth in the quarter. We have clear line of sight to how we're going to adjust and fix that. That business will improve in 2026, but not the level that we expect our business to perform at.

And we'd be highly disappointed if we weren't closer to market growth to that business in 2027. And Daskabee is doing well. They've got a nice set of product launches coming over the next nine months. And our neuromod business is growing double digit. So overall, MedSurg is a tick lighter in 26 than we anticipate, and we anticipate that business will improve as the kind of quarters move on in 26 and we'll have a stronger 27.

On the WAMGR drivers, I think we're pretty clear at the investor day that we were at 8% moving to 9% over the LRP.

So I believe that was the message on the WAMGAR. So we call it 8% moving towards 9% because we're in the right high-growth markets. So I think that's consistent.

LRP. LRP. Oh, and LRP, I mentioned it in the previous commentary. So what we are confident in giving you now is we're confident in our ability to continue to have the discipline to improve margins at that 150 basis points. We're confident in our ability to execute double-digit EPS over this LRP period. And on the sales side, obviously with a guide at six and a half to eight, that puts pressure on the 10% plus guide you gave at LRP.

So I would say that's likely an upside scenario at this point, but it's premature for us to give you a LRP organic revenue growth number at this point. And let us work through our strategic plan and launch cadence, and we'll update that over the course of this year. Great. Thank you.

Yeah, thanks, Josh. So we'll see less mixed benefit than what we expected at the start of the year. So that's why we expect our gross margins now will be slightly lower than 2025. But what we're doing is really driving leverage across OPEX. So most immediately, we put in much more restrictive spend controls across the company. So what we're doing is we're reducing spend that isn't correlated to revenue generation or that isn't pointed at our key product pipeline programs that we have in place.

You know, we've also had more broadly a number of org structure optimization initiatives in place that include scaling our centralized shared services. We've got a number of AI, automation, other initiatives already in place, Josh, that drive cost efficiency and productivity. And so we're looking at those for what we can accelerate. and then as it relates to the R&D portfolio, we're looking across each of the businesses there, ensuring that we're appropriately fueling and appropriately focusing on the most impactful programs.

But then those that are less impactful, we're looking at how we can trim those. So we've got a number of initiatives, Josh, focused on how do we drive our OpEx toward the most impactful areas of the business and toward revenue generation and then everything else we're squeezing.

Yeah, it's definitely gone slower than we anticipated. We had too much commercial turnover is the bottom line over the course, taken over the course of the last six to nine months. And we certainly learned from that. We made adjustments to it. But at this point in time, we feel we have the right leadership structure in place, you know, from region managers on up that are so key to driving a business like this. We have quite a bit of turnover at the manager level, clinical rep level, and territory level.

And so a lot of learnings from that as we look forward to Penumbra. But I would say on the management side, that's all been filled up on the region managers, which is important. And we've had nearly 100 people that have been hired in our various stages of training, both clinical reps and territory reps, to really strengthen that commercial team, which is really needed not only for case coverage, but also to drive the appropriate patient activation events and pull through to appropriate procedures, which is really part of the business and an area that Axonics did really well. So we're also leveraging a lot of the internal capabilities from Watchmen and others. But it's primarily been a commercial disruption issue that has lingered farther than we wanted it to.

But at this point in time, we have made the appropriate hires, the appropriate training, the appropriate investment, and we are confident that we'll see an improvement in that business as the quarters progress.

Yeah, thanks, Vijay. So we intend to, the $2 billion, we've got $1.5 billion on the balance sheet now, we project our cash over the second quarter, we'll fund that through cash on hand. We've been restricted from trading. We will be restricted at least through the Penumbra shareholder vote on May 6th. But as soon as we're not restricted, we intend to repurchase 2 billion shares, $2 billion worth of shares, as I mentioned. And why now is we look at the stock price. We look forward at the outlook for the company that we have, our confidence in the company, the pipeline. We think that's a great use of our capital.

Yeah, I would just comment on Penumbra in general. We've gotten to know their leadership team extremely well. We've really focused on the winning spirit of the, you know, the momentum of the ICBT team we have and the potential additions of Penumbra we think is a very, very powerful business in combination over time. We've said many, many times that we essentially plan to run Penumbra as a business unit consistent in how we do Boston Scientific.

Global presidents keeping their strong commercial team intact, keeping their R&D pipeline. So we have a very solid way to maintain and enhance the penumbra momentum post-closing. We had the shareholder vote on May 7th. We're hopeful and confident that that will be approved as planned.

Thank you.

Yeah, we're not going to call it a specific number for outlook on concomitant specific and watch standalone a little bit. I think we gave pretty good guide as to what we see as appropriate guidance for the full year on Watchmen, which is global mid-teens, U. S. low to mid-single digits, Loaded mid-teens. Loaded mid-teens. Loaded mid-teens, sorry. My bad. I was thinking of EP. Loaded mid-teens for U. S. watchmen and international plus 20. Mid-teens growth globally.

So that's our outlook, which is obviously a slower outlook than what we saw in first quarter, but it reflects what I mentioned earlier on overcoming some very, very strong comps, overcoming some efficiency issues that we see that I highlighted before, and more of a trend towards stronger and stronger concomitant and a less strong weakening trend in standalone.

Now, over time, we aim to try to improve that based on the champion results, the investments we're making. But as I mentioned, you have concomitant strengthening, and standalone currently less strong.

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