LivaNova PLC

NASDAQ:LIVN

Earnings Call Transcript 2023-Q1

[Operator]

Good day ladies and gentlemen and welcome to the LivaNova PLC First Quarter of 2023 Earnings Conference Call. [Operator Instructions] As a reminder, this conference call is being recorded.

I would now like to introduce your host for today's call, Mr. Matthew Dodds, LivaNova's Senior Vice President of Corporate Development. Please go ahead, sir.

[Matthew Dodds, Senior Vice President of Corporate Development]

Thank you, Bailey and welcome to our conference call and webcast discussing LivaNova's financial results for the first quarter of 2023. Joining me on today's call are Bill Kozy, our Chair of the Board of Directors and Interim Chief Executive Officer; Alex Shvartsburg, our Chief Financial Officer; and Briana Gotlin, Director of Investor Relations.

Before we begin, I would like to remind you that the discussions during this call will include forward-looking statements. Factors that could cause actual results to differ materially are discussed in the company's most recent filings and documents furnished to the SEC, including today's press release that is available on our website. We do not undertake to update any forward-looking statement. Also, the discussions will include certain non-GAAP financial measures with respect to our performance, including but not limited to sales results which will all be stated on a constant currency basis. Reconciliations to the most directly comparable GAAP financial measures can be found in today's press release which is available on our website. We have also posted an earnings update to our website that summarizes the points of today's call. This update is complementary to the other call materials and should be used as an enhanced communication tool. You can find the update and press release in the Investors section of our website under News Events & Presentations at investor.livanova.com.

Now, it is my pleasure to introduce you to Bill Kozy. Bill joined LivaNova's Board of Directors in 2018. After the conclusion of his 42-year career at Becton, Dickinson, where he retired as Executive Vice President and Chief Operating Officer in 2016. At BD, he served as a member of the corporate leadership team and held various executive roles since 1988. As a result, he brings expertise in strategy execution, operations and financial discipline.

With that, I will turn the call over to Bill.

[William Kozy, Chairman & Interim Chief Executive Officer]

Thank you, Matt and thank you, everyone, for joining us. It is my pleasure and privilege to welcome you to LivaNova's conference call for the first quarter of 2023 as LivaNova's Chair and Interim Chief Executive Officer.

First and foremost, on behalf of the Board and the executive leadership team, I'd like to express our gratitude to Damien McDonald for his dedicated leadership and countless contributions to the company over the last 7 years. We wish him all the best in his future endeavors. In this interim role, my focus is firmly on patients, performance and execution. In the coming weeks, I'll continue to engage with our global customers and colleagues, as well as the investor and analyst communities. Even though I'm new and learning, I'm already working alongside our experienced executive leadership team and the Board and I do remain confident that we'll facilitate a smooth and positive transition as we search for LivaNova's next leader.

For the remainder of the call, I'll discuss our first quarter results and then turn to our strategic portfolio initiatives. After my comments, Alex will provide additional details on the results and increases to 2023 guidance. I'll wrap up with closing remarks before moving on to Q&A.

In the quarter, we achieved 13% revenue growth marked by strength in the Cardiopulmonary and Neuromodulation businesses, while advanced circulatory support remained unfavorably impacted by a decline in severe COVID cases. We were particularly pleased with the way the Rest of World and Europe regions drove results, especially in emerging markets. Worth noting, these regions comprised 47% of total company revenue in the quarter, up from 43% in the prior year period.

Now, turning to segment results. For the Cardiopulmonary segment, revenue was $132 million in the quarter, an increase of 18% versus the first quarter of 2022. Oxygenator revenue grew in the high teens, driven by higher demand and improving supply chain performance. Heart-lung machine revenue increased in the low double digits, driven by new installations and replacements in the Rest of World and Europe regions. As a reminder, our Essenz heart-lung machine received U.S. FDA 510(k) clearance in March and approvals from Health Canada and the Japanese PMDA also during that first quarter. Additionally, we initiated a broad commercial release in Europe. We now expect Cardiopulmonary revenue to grow 5% to 7% for full year 2023.

Our revised forecast includes more clarity around the rollout of Essenz based on recent approvals. In addition, our revision now incorporates the strong first quarter performance in oxygenators. Alex will comment on some underlying factors that impacted the first quarter result in Cardiopulmonary. Epilepsy revenues increased 11% versus the first quarter of 2022, with strength across all 3 regions, including growth in both new and replacement implants. U.S. epilepsy revenue increased 8% year-over-year, driven by growth in total implants, higher realized price and product mix.

In the U.S., we are continuing to emphasize our commercial strategy in comprehensive epilepsy centers. As many of you know, these CECs currently do the majority of surgical epilepsy procedures and our focus on engaging with KOLs at these sites remains a top priority. Epilepsy revenue in Europe grew 14% versus prior year, led by the U.K. The Rest of World region achieved 30% growth led by Brazil.

For the full year 2023, we continue to expect global epilepsy revenue to grow 3% to 5% as we take a fresh look at the factors driving new patient surgical penetration. I will be spending a notable amount of time with our key customers and KOLs. And again, Alex will comment on some underlying factors that impacted that strong first quarter result in epilepsy.

ACS revenue was $10 million in the quarter, representing a decrease of 16% from the first quarter of 2022. Results continue to be impacted by the year-over-year reduction in severe COVID cases and in part by product mix, partially offset by growth in non-COVID cases. Our field data suggests ACS case volumes related to COVID declined approximately 90% year-over-year as fewer hospitalized patients progressed to a severity that required ECMO therapy. However, that field data also suggests ACS non-COVID case volumes increased versus the first quarter of 2022, driven by the easing of hospital capacity constraints and account acquisition.

For 2023, we continue to expect ACS to grow 4% to 6%, with the majority of the growth in the back half of the year. As a reminder, this is the last quarter this business will be significantly impacted by COVID comparisons.

Turning now to the strategic portfolio initiatives. DTD revenue in the first quarter was $2 million. For 2023, we now anticipate DTD revenue of approximately $8 million, primarily from the RECOVER study. The RECOVER study continues to advance. In March, the interim analysis for the 475th patient in the unipolar cohort was completed and confirmed the study's continuation. Subsequently, we randomized the 500th unipolar patient into the trial. Upon receipt of the 12-month follow-up data for the 500 unipolar patients, we will conduct a final analysis and expect the publication of the study results by late 2024.

Now that enrollment in the unipolar cohort is complete, our recruitment efforts have been refocused on the bipolar cohort. We expect to reach 150 bipolar patient implants in late third quarter or early fourth quarter. By now, I'm sure you familiarize yourself with the RECOVER study. I recently met with 2 of the study's principal investigators, Dr. John Rush and Dr. Charles Conway. These conversations reflect the continued excitement from the KOL community. And I hope you appreciate the company's total commitment to finish this initiative.

Moving now to OSA; the OSPREY trial continues to progress with 24 study sites actively recruiting patients. Similar to my comments on DTD, myself, the Board and our project team remain committed to this project as well.

In heart failure, the closeout of the ANTHEM clinical study is in progress. We have fully defined most of the accelerated costs in 2023, part of which occurred in the first quarter. Therefore, our expectation is that the overall R&D spend related to heart failure this year will be approximately $24 million.

With that summary, I'll turn the call over to Alex.

[Alex Shvartsburg, Chief Financial Officer]

Thanks, Bill. During my portion of the call, I'll share a brief recap of the first quarter results and provide commentary on 2023 guidance.

Turning to results; revenue in the quarter was $263 million, an increase of 13% versus 2022. In the quarter, we saw strong oxygenator demand, better-than-expected replacement implants and some accelerated orders. Additionally, we were able to continue to drive strong realized price from actions taken in the second half of 2022. Foreign exchange in the quarter had an unfavorable year-over-year impact of approximately $7 million or 3% of revenue. Adjusted gross margin as a percent of net revenue was 69% compared to 71% in the first quarter of 2022. Adjusted gross margin was unfavorably impacted by inflationary pressures, geographic and product mix, partially offset by pricing improvements.

Adjusted R&D expense in the first quarter was $46 million compared to $40 million in the first quarter of 2022. R&D as a percent of net revenue was 18% versus 17% in the first quarter of 2022. The year-over-year increase was driven by continued investments in strategic portfolio initiatives and the costs associated with closing out the ANTHEM trial. Adjusted SG&A expense for the first quarter was $108 million compared to $102 million in the first quarter of 2022. SG&A as a percent of net revenue was 41%, down from 43% in the first quarter of 2022. The year-over-year increase on a dollar basis was driven by higher sales and marketing expenses. These include Essenz launch expenses and variable costs associated with increased revenues.

Adjusted operating income was $27 million compared to $28 million in the first quarter of last year. Adjusted operating income margin was 10% compared to 12% in the first quarter of 2022. Adjusted operating income was negatively impacted by: one, product and geographic mix; two, incremental investments in the OSA and DTD programs, as well as accelerated spend related to the closeout of the heart failure program; and three, commercial investments focused on the Essenz launch. These key elements negatively impacted adjusted operating income margin by 300 basis points versus the prior year. Adjusted effective tax rate in the quarter was 6% versus 7% in the first quarter of 2022. Adjusted diluted earnings per share was $0.43 compared to $0.48 in the first quarter of 2022.

Our cash balance at March 31 was $214 million, in line with $214 million at year-end 2022. Total debt at March 31 was $542 million, in line with $542 million at year-end 2022. Net debt, including restricted cash at March 31 was $72 million. Adjusted free cash flow for the quarter was $20 million, up from $17 million in the prior year. Free cash flow generation was improved by working capital management. Capital investments were $8 million in the first quarter compared to $5 million in the prior year quarter.

Now, turning to our revised 2023 guidance. As Bill mentioned, based on our performance during the first quarter, we are increasing our full year 2023 revenue and earnings per share guidance. We now expect 2023 revenue growth on a constant currency basis between 4% and 6% and continue to assume approximately a 1% tailwind from exchange rates. We now expect adjusted diluted earnings per share in the range of $2.50 and $2.70 with adjusted diluted weighted average shares outstanding to be $54 million for the full year. Adjusted free cash flow is still expected to be in the range of $80 million to $100 million.

In summary, I'm encouraged by the first quarter top line performance and we remain positioned to drive operating leverage by year-end.

With that, I'll turn the call back over to Bill.

[William Kozy, Chairman & Interim Chief Executive Officer]

Thank you, Alex. LivaNova's first quarter performance demonstrated continued progress across the portfolio and positions the company well to deliver on its pipeline and its full year guidance. We're eager to build upon the first quarter results with a firm focus on patients, performance and execution throughout the remainder of 2023.

In closing, we're committed to our DTD and OSA programs. And let me be equally clear, we're also focused on accelerating new patient penetration in U.S. epilepsy, continuing strong performance in the Rest of World and Europe regions and, of course, driving the successful launch of Essenz. Our employees remain dedicated to helping patients worldwide and are focused on long-term innovation and shareholder value creation. And by the way, I thank them for the welcome they have extended to me over the last couple of weeks.

With that, Bailey, we're ready to open the call for questions.

[Operator]

[Operator Instructions] The first question today comes from the line of Rick Wise from Stifel.

[Rick Wise, Stifel Financial]

Good morning, everybody. Good morning, Bill. Good to hear your voice again.

[William Kozy, Chairman & Interim Chief Executive Officer]

Good morning.

[Rick Wise, Stifel Financial]

It was great to hear you spot in such clarity, some of your priorities, patients performance execution and I appreciate the summary at the end. But maybe just for those who maybe know you less well than I do, maybe talk in a little more detail about your priorities during this -- how you're going to go about driving these things during this interim period? Do you -- how active a role do you expect to play? And maybe taking those -- the NPI build, the focus on the Rest of the World and the Essenz launch, I mean, how will your typically hands-on detailed approach help drive that forward?

[William Kozy, Chairman & Interim Chief Executive Officer]

Rick, thank you for the question. I've talked a lot with all of the colleagues here at LivaNova and the interim role, as you already know, is something to be thought through. But the way I've thought through it goes as follows. As I mentioned earlier, attention on patients performance and execution. And that's from my personal perspective, that's head down and all in. So I would challenge myself to operate in this interim role, just the same as I was used to operating in my prior roles. The Board had requested this as we made this transition. The organization has been just terrific in the way that we're starting to collaborate. But I'd reiterate the 4 initial takeaways from the first couple of weeks. And the way I just closed, we're really committed to the SPI. We're really going to look closely at epilepsy and what can we further do to improve our performance in surgical penetration.

We're going to look at how can we take best advantage of this already strong performance that we're seeing in the region. My comment about 47% of revenues in those areas, it's notable. And it's a really good signal about how the company is progressing when you think about the year-on-year success. And then Essenz, also at the top of the list, as I mentioned. Just to circle back, I want to make sure I've left it clear with you that interim refers to the time frame that I will be here. It in no way refers to my commitment to the business or doing everything I can to work with this executive team and to effectively make better the performance of the company as we seek the next leader.

[Rick Wise, Stifel Financial]

That's a great answer, Bill. I'm going to ask 1.5 follow-ups. One, the -- the first is on the guide, to what extent is the 2023 guide thoughtfully conservative maybe as usual? Or is it extra conservative given this transition period? And maybe you could talk to us at a high level again, how do you see -- how is the Board thinking about the search for the next leader inside the company outside? What are your priorities? What are you looking for? What characteristics as you pursue this search?

[William Kozy, Chairman & Interim Chief Executive Officer]

That 1.5 share sounded like two but let me show that. So Alex did a nice job of sharing with you the kind of the drivers behind the 13% growth in that quarter. What I think is prudent and it becomes more prudent at the start of the year. You just make sure you've got some understanding of underlying factors. And there are definitely a couple, I mean even the new guy caught a couple of things in the P&L that said, just this looks a little bit favorable. I'll throw you an example. I said, geez, I don't think we want to count on Russia, okay, each and every quarter and to extend that out as just one example. So, Alex has got a full handle on that. And you know what, I'll have him in a second, add a little color to that. But I'd like to think that we're being prudent and particularly at this stage of the year.

Now to your second question there, the Board has really done a thorough job in their specificity about the next CEO. And I would not drag you through what actually is a pretty thorough job spec for the next CEO. Let me hit the 100,000-foot level. The nature of this business is that great strategic capability is meaningful. And that would certainly going to be at the top of the list. What -- I guess, the real secondary expectation though for us is to link that ability to look longer term but to align that thinking with really favorable operating acumen and the ability to link those 2 things to continually improving financial outcomes. It sounds pretty -- I guess, pretty obvious. But that's really at the top of our list at that 100,000-foot level.

Things like cost discipline and things like operational excellence, they are going to be just as important as trying to find that person who has really talented looking around the corner and particularly with these set of platforms, particularly if you think about SPI, okay? Those 2 things really become essential to ensuring the success of the company, if and when those SPIs should appear. I hope that gives you a little bit of a sense.

[Rick Wise, Stifel Financial]

Appreciate it.

[William Kozy, Chairman & Interim Chief Executive Officer]

Alex, anything to add on the -- my prudent comments about the guidance.

[Alex Shvartsburg, Chief Financial Officer]

As you said, Bill, we're looking at the underlying market dynamics and how that really translates into growth for the remainder of the year. As I mentioned, we saw a strong oxygenator demand. We saw a better-than-expected replacement implants in epilepsy. And we also saw some accelerated orders into the quarter, so kind of a phasing thing. And we just want to make sure that all of these parts are sustainable and that was the rationale for our guide.

[Operator]

The next question today comes from the line of Michael Polark from Wolfe Research.

[Michael Polark, Wolfe Research]

Hi, good morning. I have 2, one on the leadership transition and one on depression. Bill, I'm curious for your perspective on this. We get this question when things like this happen. Why now Damien's transition? Obviously, a few weeks ago, it was kind of a straightforward question to answer with the revenue preannounced. It wasn't about the quarter. But how do you see this? And is there anything in here that -- the Street needs to be concerned about? Or is it to your other comment, head down and execute. And no, there's nothing else here. So any color there would be helpful.

[William Kozy, Chairman & Interim Chief Executive Officer]

Yes. Thanks for the question. As we did try and talk about earlier, I mean, Damien resigned and we certainly appreciate his leadership and the things he did for the company. There were -- there was no new job that was announced. There were no personal issues reflected. There was a very constructive commitment to help the company in the transition window throughout the month of May. And all those things are right on the rails. So at this point in time, that's kind of our -- that's the understanding of everything that happened. And it's that simple. I don't have any story to add.

[Michael Polark, Wolfe Research]

Understood. The -- on depression, we just like a reminder on -- look, for the unipolar cohort, the 500 patient is in, the premise now is followed for the full 12 months and then we'll see what we see. I guess can you remind us at the 475 patient interim analysis, these rolling interims tested for early futility and early success. And I think there are some criteria as to what kind of futility might have looked like at 475 and what early success might have looked like at 475 in terms of separation VNS versus control. So, would you be willing to frame up those parameters like you were above this, you were below this and you're somewhere in the middle. And so you're continuing and then the follow-up there is like what is required at 500 fully followed in terms of separation to be statistically significant at the end of this? So any color there would be great.

[William Kozy, Chairman & Interim Chief Executive Officer]

Yes. Thanks for the question. Here I am in day 19. So I'm going to flip this right over to Matt, okay, who really is a much better source of information.

[Matthew Dodds, Senior Vice President of Corporate Development]

Hi, Mike. So all right, for your questions, at 475, the potential to stop enrolling early, the upper bound that was around 80%. And then the futility, it got only up to 45%. So it's somewhere in between there. There is no look at 500, so we are going full 12-month enrollment with all patients which that goes out to mid-2024. Again, the study was always designed for 500 patients in both arms unipolar and bipolar. And to your specific question, primary endpoint is time and response. It's somewhere in the low 60% range to hit the p-value of [indiscernible].

[Operator]

The next question today comes from the line of Matt Taylor from Jefferies.

[Matthew Taylor, Jefferies]

Hey, good morning. I was hoping that you could talk a little bit more about the epilepsy trends, both the overperformance and replacements, where did that come from? And then the focus on new patients. And I know in speaking with Matt, maybe a month ago or so, he was telling me about some interesting things you're doing with the incentives and the sales force, I'd love if you could touch on that.

[William Kozy, Chairman & Interim Chief Executive Officer]

Yes. Let me ask Matt to go first but then I do want to add some comments.

[Matthew Dodds, Senior Vice President of Corporate Development]

All right. So Matt, I'll start with EOS, then I'll turn it over to Bill for NPI and then we can flip back on some of the things we've recently done. So for EOS, we still believe we're largely through the COVID-related backlog. Again, not perfect math but that's our thinking. Also remember that first quarter was the lowest comp of the year in 2022. So we did have an easier comp this quarter. Now all that said, we did put some programs in place late last year to help identify patients lost to follow-up. And we think we might be seeing some early success there. But again, it's early. So that's what really drove the EOS.

I'll turn it over to Bill for some comments on NPI, then I'll talk a little bit about some of the things we've been looking at on the sales force.

[William Kozy, Chairman & Interim Chief Executive Officer]

By way of background, I think some of you might recall that some of the previous calls, we've referenced the really important efforts to make sure that we've got our sales organization appropriately targeted, resourced and capable of really dealing with the KOLs and these comprehensive epilepsy centers. And that continues and I believe in a very constructive way, admittedly, the volume is up there but it's being done in a very constructive approach to our customers. And then, the second thing that as a senior management team, we've all had a chance to chat here over the last couple of weeks. This is a very high priority strategic parameter for all of us. So I'll be out next week the first time I've had a chance but I'll start -- you've heard me reference maybe a few times, my commitment to getting out. I'll be out next week for a couple of days. I'll follow that up frequently, making sure that we have increasing depth of understanding of, a, the customer, b, the surgical penetration expectations and c, of course, most importantly, what else should we be doing to arm our sales reps with better information and capability.

[Matthew Dodds, Senior Vice President of Corporate Development]

And then as your follow-up, we did mention last quarter that we did make some changes to the U.S. epilepsy sales force late last year and then early into this year, a lot of involuntary change. In general, we had about 20 people change positions. And what we were highlighting was the quality has been very high for the replacements we've had of the 20, 12 have direct neuromodulation experience. Others are in areas like diabetes and neurosurgery. So very encouraging and early days, some of these new hires have made already a nice contribution to the overall performance.

[Matthew Taylor, Jefferies]

Great, very fair. I appreciate it.

[Operator]

The next question today comes from the line of Adam Maeder from Piper Sandler.

[Adam Maeder, Piper Sandler]

Hi, good morning, everyone. And congrats on this starts [ph] to the year. I wanted to start on the CP business and just get a little bit more color there. It looks like the performance was really driven OUS was U.S. was a little bit softer. Are you able to just kind of flesh out those trends by region for us? It's perhaps just simply driven by Essenz [ph] in timing there but any thoughts would be helpful. And then, can you also just remind us how you're pricing Essenz. I think it's being priced at a premium but would love to get some color there as well? And then I had a follow-up or two.

[William Kozy, Chairman & Interim Chief Executive Officer]

Yes. Alex and I've had this almost identical conversation. I'm just going to flip it over to him because he's really got his arms around it.

[Alex Shvartsburg, Chief Financial Officer]

Adam, so CP, we saw really solid demand for oxygenators and the heart-lung machines. We have seen some really good replacement volumes, OUS. We expect revenue from Essenz to start to contribute meaningfully in the second half of the year. So that was sort of if you look at the regional breakdown, the U.S. was less positive in the quarter but that's because customers are deferring orders at this point in time. We just got the clearance in the U.S. and we should start to see volumes ramp in the second half. The other component of our solid performance on the consumables business is really -- we're seeing some of our competitors experiencing supply chain challenges. And frankly, our supply chain is -- our team is doing extremely well and we're able to capture some of the placements. So, feeling really strong about what and how the business performed in the first quarter and really looking forward to the remainder of the year.

[Adam Maeder, Piper Sandler]

That's helpful color, Alex.

[William Kozy, Chairman & Interim Chief Executive Officer]

Yes. One other thing just in terms of price on Essenz, yes, we've been commenting to a premium price offering. Obviously, the features and benefits of Essenz are superior. At the same time, the cost of the unit itself is higher. But -- so we are going to price Essenz at a very reasonable premium that customers will still appreciate.

[Adam Maeder, Piper Sandler]

Great. Thank you for the fulsome response. Maybe switching gears to -- start to sleep apnea. I guess, first, I was hoping to ask how you're thinking about time lines for that program, I think before you were anticipating FDA approval by year-end 2024. I wanted to see if that's still the case? And then second, the data from the THN3 trial were recently published in a medical journal. Just any color or thoughts on that publication. And then, just one question that I get sometimes from investors is just talk about kind of the learnings and any changes to either the trial design or the device design with OSPREY relative to that previous study?

[Matthew Dodds, Senior Vice President of Corporate Development]

Sure, Adam. It's Matt. I'll go through all those. So for OSA, we are still making progress on recruitments, implants. We have increased the study sites from 20; we're now at 24. So that's going well. We've incrementally invested on several fronts to drive the recruitment funnel. But remember, this is a randomized trial. Other trials have not been randomized. So there is some drop-off in the funnel. We've had a strong funnel of patients but there is some drop-off. So we do expect to complete enrollment now in 2024 and looking at FDA approval now in 2025. And then, related to the JAMA publication, our take here is that generally quite positive. It highlighted a lot of what you've already seen in THN3, especially in the areas of the primary end points and how the author felt we did on that. So I think that's the full takeaway from the JAMA publication.

[Adam Maeder, Piper Sandler]

Okay. That's helpful, Matt. And just any flavor for changes to the device itself or trial design? And then -- sorry, I have one more follow-up for you guys.

[Matthew Dodds, Senior Vice President of Corporate Development]

Sure. So no changes to OSPREY, the same. In terms of the device, nothing new to report there on the current device. We basically just tightened up a few things on the existing device to make it a bit more reliable.

[Adam Maeder, Piper Sandler]

Okay, got it. And then, just one last one clarification on the cost savings from the heart failure program. I guess it was a little bit unclear to me in the prepared remarks. What is the expectation for any cost savings this year? Is anything reflected in the updated guidance?

[William Kozy, Chairman & Interim Chief Executive Officer]

Yes, Alex has got this one, Alex, would you, please?

[Alex Shvartsburg, Chief Financial Officer]

Yes. So as we mentioned, the total cost we estimate to be around $24 million for the year. Look, our #1 priority here is patient safety. So it's a complex implanted device and I want to make sure that we take patients into account and patient safety into account. So last year, we spent roughly, call it, $27 million. So the savings this year are minimal but we expect to drive significant savings in 2024.

[Adam Maeder, Piper Sandler]

Okay, perfect.

[Operator]

The next question today comes from the line of Mike Matson from Needham & Company.

[Mike Matson, Needham & Company]

So Bill, I think you mentioned that you were planning to exit Russia. So correct me if that's wrong but can you just tell us how much of your revenue is coming from Russia?

[William Kozy, Chairman & Interim Chief Executive Officer]

That was one of the things that caught my eye. You can -- you know what was said. And then in the first quarter, I would say it was a couple of million. It was notable. I don't have the exact number here in front of me. Alex, do you?

[Alex Shvartsburg, Chief Financial Officer]

Yes, I do. It's roughly 1% of our revenue, right, historically. So it wasn't a significant amount but we're not planning and we're not incorporating those revenues into our guidance. So, the ability to serve those customers in the quarter, just not necessarily counting on a repeat order pattern throughout the remainder of the year.

[William Kozy, Chairman & Interim Chief Executive Officer]

Yes, we got no reason to treat it anything other than a onetime event at this particular moment.

[Mike Matson, Needham & Company]

Okay, got it. And then, as far as the -- just on the trial spending. So you commented on heart failure in the prior Adam's questions. But I guess, just the sequencing of the $24 million in cost this year, I mean, is that kind of spread evenly throughout the 4 quarters? Or will it be more kind of dated to the first half of the year?

[William Kozy, Chairman & Interim Chief Executive Officer]

It's going to be phased. We actually accelerated the spending in the first quarter as we obviously seeing patients come in for their visits and really closing out the components of the sites. So I think that we'll see an uptick in spend in the first half and then it should start to ramp down by the end of the year.

[Mike Matson, Needham & Company]

Okay. And then just as far as RECOVER goes, I mean, now that you've hit the 500 patient mark, I know you're focused on the bipolar now but I mean is it reasonable to assume the spending levels there would be lower for the follow-up period or...

[William Kozy, Chairman & Interim Chief Executive Officer]

No, it's not. Because we call our focus now shifts to the bipolar cohort. So recruitment of the bipolar patients, obviously continuing to monitor the unipolar patients. So our spend really does not go down at all this year.

[Operator]

The next question today comes from the line of Matt Miksic from Barclays.

[Unidentified Analyst]

Hi, this is Sarah on for Matt. Just a quick follow-up on the RECOVER study. I believe you said you received final analysis and results by late-2024 [ph] instead of maybe earlier was mid-24, is coverage decision by year-end '24 is still the right way to think about this?

[William Kozy, Chairman & Interim Chief Executive Officer]

Yes. Sure, Sarah. So we're still expecting the data around mid '24. We're now in the 12-month follow-up. There's going to be a couple of months of analysis but we should have it mid-24 and we still expect a publication around year-end of 2024.

[Unidentified Analyst]

Okay. And then another is a theme for this quarter, we've seen is there seems to be a significant ramp in utilization and volumes across many of our end markets. Can you talk about how your businesses participated in this ramp? And if they still remain below historical utilization levels? Any color on that would be helpful.

[Matthew Dodds, Senior Vice President of Corporate Development]

I can comment to that, Sarah. So we've seen a market recovery. We continue to see a market recovery in volumes. So as we think about our sources of growth in the quarter, particularly in the emerging markets, areas like China where, if you recall, last year this time, those regions were really going through the omicron-COVID impact. And so, we are absolutely seeing that recovery. And that's part of the reason we saw the substantial growth in the quarter. So we said it was an easier comp, if you will. But we feel encouraged by the -- what we're seeing from a customer demand perspective.

[William Kozy, Chairman & Interim Chief Executive Officer]

And then in epilepsy, we still track on a quarterly basis the epilepsy monitoring unit or EMU trends, they're still not back to pre-COVID levels. We estimate they're around 85%, 86% capacity and that covers all surgery, not just E&S. But then internationally, our business there is well above pre-COVID levels. So that has rebounded quite nicely.

[Operator]

There were no additional questions meeting at this time. So, I'd like to turn the conference over to Bill Kozy for any closing remarks.

[William Kozy, Chairman & Interim Chief Executive Officer]

Well, thank you, everyone, for joining today's call. On behalf of the entire team, we appreciate your support and your interest in the company and we look forward to speaking with you soon. Thank you.

[Operator]

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