I am not a cardiologist, but I do work with catheters and the same techniques as an interventional radiologist. I got interested in this company after hearing some cardiologists discussung it. I did start a position because I think the device is still in its infancy and will continue to grow for a while.
The main differentiator in the Impella products is that they were designed primarily as catheter based systems, rather than a catheter implementation of a surgical device (which is what the intra-aortic balloon pumps look like). I think they can continue to make it smaller and with that the downsides to putting one in drop significantly. If they can get down to an 8 French sheath size most closure devices will be compatible and really it would be an added 10-15 minutes of procedure time to place an Impella (I don’t know how long it really takes to set up, but it should onky take that long to access the artery, place and position the catheter, then remove the catheter and place an arterial closure device). Being easy to use goes a long way in adoption in the interventional cardiology field.
I think it may even go the other way, where cardiologists stretch the “high risk” definition to include more routine patients, use the Impella, just for a bit of added protection. This is assuming that the reimbursement is a net positive. With a smaller catheter size, the downsides to putting one in are reduced such that the potential benefits can be lower and still outweigh the risks.
I can also see in the future extension of the catheter to a biventricular assist by running the motor in reverse in the right atrium across the pulmonic valve. Also, some will probably use it for longer term ventricular assist than the currently documented 6 hours, possibly as a bridge to transplant.
In the end, the reality is that the success or failure of medical devices has as much to do with regulatory issues (they already got their approval) and physician preference as actual medical benefit. I did well with ISRG knowing that even though the da Vinci prostatectomy is probably no better than laparoscopic techniques, urologists preferred it and could market it, so it became the only thing they offered. A cardiologist would not tell a patient that for an extra $x they could have the Impella assist device. They’ll just say that they use this device, it protects their body during intervention and shortly thereafter, and patients will just agree.
Saul and others can probably provide a better look into the financials. I am still learning the financial side of things so I try to focus on companies and industries that I think have staying power.