For all you Abiomed fans, Shockwave medical is worth a look, because ABMD invested in and collaborated with Shockwave to incorporate Shockwave’s IVL into its own physician training.
Shockwave’s business is straightforward, it uses the same ultrasonic technology that is used to break up kidney stones to break up calcium inside of lesions without damaging blood vessels to clear arteries. It sounds like super effective technology. Revenue increased from $1.3 MM to $7.3MM in its first quarterly earnings since its IPO. Gross margins increased a little to 58%. Its burning cash, but has $138MM on hand after raising $110MM from it’s IPO. It has 53 sales reps, a number that they say needs to be increased. They are predicting $33MM - $36MM sales for the year, which was, apparently, higher than expected. SWAV’s loss from operations was $12.2MM, so they have some, but not a huge amount of runway, especially considering that they are going to significantly increase their staff. That said the stock popped about 15% after its first earnings release.
It’s just starting to bring in revenue, but its Price to Sales would be 55.5 based on this years estimates, so this is very, very high, but SWAV estimates its TAM at $6.7B for aortic stenosis, Coronary Artery Disease (CAD), and Peripheral Artery Disease (PAD).
Long SWAV 2.1%
PS I will provide an update on ARNA shortly for those interested.
This was discussed a while ago shortly after its IPO.
Shockwave came to one of my hospitals and presented its technology. Looks and sounds cool, but I wasn’t convinced about its effectiveness. A few sponsored studies here or there showing slightly better outcomes just isn’t going to cut it. I can’t speak for aortic stenosis or coronary disease, but there’s no way it becomes anything more than a small player in peripheral artery disease (in my opinion). Might be a buyout candidate and there’s some low hanging fruit to grab (some hospital administrators just like having new tech) but I don’t see any ABMD/ISRG type gains.
What type of data would convince you that this technology is effective?
What type of data would convince you that this technology is effective?
It’s been a while but the difference in outcomes simply wasn’t high enough, and the patient groups were relatively small. If the difference is not great enough even in a carefully selected sponsored trial I would want to see it in an independent study. Given how new it is I also haven’t heard from others I know in academia who could at least give me anecdotal evidence that they see it working better than a regular balloon.
I believe that it’s effective, but is it worth the extra cost and hassle of a new device type? It’s relatively simple to use but still requires slightly different setup, a generator of some sort, and of course shelf space to stock the device.
The sales rep focused a lot on the fact that the angioplasty didn’t need to be as high pressure as with traditional angioplasty, so theoretically it’s safer. It simply wasn’t all that convincing – I haven’t seen that pressure is the issue with angioplasty, at least not in the lower extremities. Maybe in the coronaries it makes a bigger difference. Otherwise it just breaks up calcium like any other angioplasty. So my question always went back to what is the added value and how is it really different from the cheaper options that we already have?
Since when have outcomes mattered much for device companies??!?!
It’s not like ABMD or ISRG have shown significant patient benefit or cost benefit, and they’ve still been stock monsters!
Theoretical benefit & composite outcomes are, sadly, often good enough.
Agreed, ABMD is a completely different device from the IABP and ISRG could rely on publicity.
But no patients know what type of balloon is used for their angioplasty. So SWAV would have to sell the operators on a new device, whether it’s through better data or better safety or ease of use or better reimbursement or other more nefarious methods. I personally wasn’t sold.
Because you are a doc and I think you are unbiased, I am taking what you say very seriously and am considering closing my position. Before I do take action, I wanted to see if you would be kind enough to answer a couple of questions. One of the things that encouraged me about the company was ABMD’s investment in SWAV. If anyone would understand the benefits and technology, wouldn’t they? Not only did ABMD invest, they are partnering to give docs training on the device. Why do you think they collaborated on the technology if it has such little value?
Just to be clear, I have little knowledge of SWAV’s financials nor their current growth prospects.
I don’t doubt that their technology is effective. I just wasn’t convinced that it has any more effectiveness than what we already have and what is already in place (along with what is already being sold by much larger companies with much more experienced salespeople). And I didn’t see an added differentiator that would help them really change the market. Impella is completely different from the IABP in that it is safer to place, even if it doesn’t affect outcomes (which I believe it does but I am not an expert). The da Vinci prostatectomy was easier to perform (for new urologists at least) than laparoscopic or open prostatectomy and had the advantage of the futuristic “robot” moniker which made the public want it.
Regarding Shockwave, no patients really know what kind of balloon is used for their angioplasty, nor do they really care or would even likely understand. It’s otherwise essentially the same type of device that we already have except it connects up to a little device that delivers an ultrasonic pulse to crack calcium rather than brute force. Sounds cool, but I didn’t see that it was actually any safer or easier to use. So what is going to drive adoption? It’s just one more device that you’d need to stock and restock, another generator to store somewhere, another sequence of events to remember for setup.
The company can probably charm and hype their way into a decent number of departments, but long term they need more than some small sponsored studies to convince users to choose them over the myriad of other options. Can it get 2% of the market, or 5%, or 10%? I don’t really know, depends on how well they can sell, or maybe improve their technology. My guess is they get bought out by one of the big names at some point so maybe there’s still some decent upside.
Why did ABMD invest? Well like I said it’s a viable product and they can sell some. I just don’t believe it will be a game changer or even a significant piece of their claimed TAM, at least for peripheral disease. Maybe they want the expertise of miniaturizing things to put them on the end of a catheter. Maybe they think the sales force will create some synergies and they are different but close enough that they don’t need to worry about competition. Or maybe they just got really good terms. There really isn’t much in terms of training so I don’t see that as a huge commitment.
I much prefer a company like Penumbra (PEN) which is much more differentiated in terms of ease of use for their clot aspiration device but still independent and focused on growing a core product.
I have no position in any of the above companies at this time.
Don’t be shaken too easily by someone who has not tried the device personally. Even an expert’s opinion is only one expert’s opinion. Someone has to be the one dentist out of five that doesn’t recommend Crest.
40 cases are being presented at Euro PCR. Maybe try to get a few of them and see what those doctors have to say.
Here is one case where they liked the I L.
One item to note is they address competitive technologies a bit:
“The novelty highlighted in our article relates to the use of Lithoplasty also in the treatment of calcified stenosis in a vascular district such as innominate artery. Traditionally, surgical intervention was the preferred way to treat these types of lesions. Over the years, with the development of endovascular techniques, surgical approach has been increasingly shelved. Despite these progresses, calcified lesions represent a hard obstacle to overcome. Thanks to the Lithoplasty technology, we were able to enhance plaque compliance by disrupting calcium deposits and then facilitate the correct stent apposition. Of note, in contrast to the other devices (ie, rotational atherectomy, cutting balloons) which generate microparticles that embolize distally, large calcium fragments generated by lithoplasty remained in situ, reducing the risk of embolization.”
Let’s look at their current competition, the drug coated balloon for peripheral vascular disesae:
82% primary patency at 12 months
2.4% clinically driven target lesion revascularization (repeat surgery)
55% primary patency at 12 months
10-20% clinically driven target lesion revascularization
Data still needs work. SWAV is on my radar for the potential cardiac treatment.
There are other issues at play:
maybe vascular or IR can do this in the office with Shockwave in the future; that changes the landscape a bit.
(anecdotal, vague recollection) I believe I had a conversation with cards about using this to crack calcium to get femoral access for procedures that require a big catheter. So this may augment other procedures to be done.
this is starting to get a bit prolonged for this board, I’ll stop replying after this. Feel free to chat biotech/med at the above link
I tried searching the board for your post on ARNA as I was out on vacation for a couple weeks but didn’t find it.
Were you able to post your thoughts on ARNA?