Boston Scientific Corp

NYSE:BSX

Earnings Call Analysis

Robust Growth and Strong Outlook in Company Performance

The company demonstrated exceptional performance in 2023, notably surpassing financial goals with one of the strongest years in its history. Q4 saw operational sales and organic sales surge by 15% and 14% respectively, coupled with a remarkable 24% growth in adjusted EPS of $0.55. The full year adjusted EPS climbed to $2.05, a 28% increase from the previous year. Despite market challenges, the company projects organic growth of 7-9% for Q1 2024 and expects adjusted gross margin for the full year to be on par or slightly below 2023's, with anticipated operating margin expansion by 30 to 50 basis points, all while aligning with a strategic long-term plan.

Outstanding 2023 Performance Marks Historical Company Success

The company's performance in 2023 was highlighted by unprecedented achievements, making it one of the strongest years in the company's history. In the fourth quarter, there was a significant 15% increase in operational sales and a 14% increase in organic sales compared to the fourth quarter of 2022, outperforming the projected 8% to 10% growth. The full year operational sales growth also reached 13% over 2022.

Earnings Per Share Reflect Strong Growth Trend

Earnings per share followed a robust upward trajectory with a 24% increase in Q4 adjusted EPS at $0.55, surpassing the expected range of $0.49 to $0.52. The full year adjusted EPS growth stood at a remarkable 28% at $2.05, indicating solid profit performance.

Global Growth Spurs Optimism

Geographically, the company saw substantial growth across all regions in the fourth quarter: U.S. by 11%, Europe, Middle East and Africa by 12%, Asia Pacific by 17%, and Latin America also by 17%. Notably, the full year growth remained robust in these regions, laying a strong foundation for future performance.

Urology and Endoscopy Divisions Shine Brightly

The Urology division experienced a stellar 10% organic growth in Q4, and Endoscopy sales surged by 12%. Neuromodulation also made significant inroads with a 7% operational growth. However, the pain franchise results remained flat year-over-year.

Prospective 2024 Outlook and Growth Strategy

The forecast for 2024 is strategically positive, with an anticipatory organic growth of 7% to 9% in Q1 and 8% to 9% across the full year. Adjusted EPS for Q1 is estimated at $0.50 to $0.52, and the full-year adjusted EPS is projected to be between $2.23 and $2.27. Despite facing margin pressures due to foreign exchange headwinds and investments in manufacturing and selling expenses, the company is focused on enhancing the adjusted operating margin by 150 basis points over the three years from 2024 to 2026.

Key Product Lines and Geographical Expansion

Peripheral Intervention sales demonstrated strength with a 12% operational and 10% organic growth in Q4. Cardiology also delivered strong results, with quarter and full-year operational and organic sales rising by 14%. Electrophysiology witnessed an exponential growth of 43% in Q4. All these highlights suggest that the company's innovative products and geographical expansion into markets like Japan and China will continue to be significant growth drivers.

Financial Health and Margin Expectations

The financial resilience of the company is underpinned by a full-year 2023 adjusted gross margin of 70.7%. Looking ahead to 2024, the company expects its adjusted gross margin to be at or slightly below the 2023 rate due to a mix of benefits from new launches and opposing FX headwinds. Moreover, 2024 is set to see an expansion of the adjusted operating margin by an additional 30 to 50 basis points, signalling a balance between making necessary investments and pushing towards the goal of a 150 basis point improvement over the 2024 to 2026 period.

Earnings Call Transcript 2023-Q4

[Operator]

Good morning, and welcome to the Boston Scientific Fourth Quarter 2023 Earnings Call. [Operator Instructions] Please note this event is being recorded.

I would now like to turn the conference over to Lauren Tengler, Vice President, Investor Relations. Please go ahead.

[Lauren Tengler, executive]

Thank you, Drew. Welcome, everyone, and thanks for joining us today. With me on today's call are Mike Mahoney, Chairman and Chief Executive Officer; and Dan Brennan, Executive Vice President and Chief Financial Officer.

We issued a press release earlier this morning announcing our Q4 and full year 2023 results, which included reconciliations of the non-GAAP measures used in the release. We have posted a copy of that release as well as reconciliations of the non-GAAP measures used in today's call to the Investor Relations section of our website under the heading Financials and Filings.

The duration of this morning's call will be approximately 1 hour. Mike and Dan will provide comments on Q4 and full year performance as well as the outlook for the business, including 2024 guidance, and then we'll take your questions. During today's Q&A session, Mike and Dan will be joined by our Chief Medical Officer, Dr. Ken Stein.

Before we begin, I'd like to remind everyone that on this call, operational revenue growth excludes the impact of foreign currency fluctuations, and organic revenue growth further excludes acquisitions and divestitures for which there are less than a full period of comparable net sales. Relevant acquisitions and divestitures excluded for organic growth are Baylis Medical, which closed on February 14, 2022, and the majority stake investment in Acotec Scientific Holding Ltd., Apollo Endosurgery and Relievant Medical, which closed in February, April, November 2023, respectively. Divestitures include the endoscopy pathology business, which closed in April 2023. Guidance excludes the previously announced agreement to acquire Axonics, Inc., which is expected to close in the first half of 2024, subject to customary closing conditions. For more information, please refer to our financial and operating highlights deck, which may be found on our Investor Relations website.

On this call, all references to sales and revenue, unless otherwise specified, are organic. This call contains forward-looking statements within the meanings of federal securities laws, which may be identified by words like anticipate, expect, may, believe, estimate and other similar words. They include, among other things, statements about our growth and market share, new and anticipated product approvals and launches, acquisitions, clinical trials, cost savings and growth opportunities, our cash flow and expected use, our financial performance, including sales, margins and earnings as well as our tax rates, R&D spend and other expenses.

If our underlying assumptions turn out to be incorrect or if certain risks or uncertainties materialize, actual results could vary materially from the expectations and projections expressed or implied by our forward-looking statements. Factors that may cause such differences include described in the Risk Factors section of our most recent 10-K and subsequent 10-Qs filed with the SEC. These statements speak only as of today's date, and we disclaim any intention or obligation to update them.

At this point, I'll turn it over to Mike.

[Michael Mahoney, executive]

Thanks, Lauren, and thank you, everyone, for joining us today. 2023 results were excellent, and our global performance represented one of the strongest years in company history, exceeding our financial goals that we set for the year. This performance is fueled by [indiscernible] and clinical evidence generation, commercial execution and the winning spirit of our global teams.

In fourth quarter '23, total company operational sales grew 15% and organic sales grew 14% versus fourth quarter '22, exceeding the high end of our guidance range of 8% to 10%. Full year '23 operational sales growth of 13% versus 2022. And while organic sales grew 12%, exceeding our guidance of approximately 11% for the full year. Importantly, 6 of our 8 business units grew sales double digit in the fourth quarter and double digits for the full year 2023 and all of our regions also grew double digits in the fourth quarter and double digits full year 2023. This performance is a testament to our category leadership strategy and our focus on innovation bolstered by commercial excellence.

Fourth quarter adjusted EPS of $0.55 grew 24% versus 2022, exceeding the high end of our guidance range $0.49 to $0.52. Full year adjusted EPS of $2.05 grew [ 28% ] versus 2022, also exceeding the high end of our guidance range of $1.99 to $2.02. Q4 adjusted operating margin was 26.6% and full year '23 was 26.3%, which is exciting because it exceeds pre-pandemic levels. We generated full year cash flow of $1.8 billion and adjusted free cash flow of $2.5 billion, in line with our expectations.

Now for our 2024 outlook. We expect healthy procedure volumes to continue in our guidance to organic growth of 7% to 9% for first quarter 2024 and 8% to 9% for the full 2024. Our Q1 '24 adjusted EPS estimate is $0.50 to $0.52. We expect our full year adjusted EPS to be $2.23 to $2.27, representing growth of 9% to 11%. This guidance excludes the acquisition of Axonics, which is expected to close in the first half of '24.

Despite pressures on margins in '24 from FX headwinds as well as investments in manufacturing capacity and selling expenses to fuel our exciting launches, we remain committed to improving operating income margins in 2024 and to our goal of improving adjusted operating margin by 150 basis points in '24 to '26. Now Dan will provide more details on those financials for both 2023 and 2024.

I'll now provide additional highlights on '23 results along with comments on our outlook. Regionally, on an operational basis, the U.S. grew 11% versus fourth quarter '22. Full year 2023 grew 10%, with particular strength in our WATCHMAN, EP, Endo and Uro business units. Europe, Middle East and Africa grew 12% on an operational basis versus Q4 '22 and 13% on a full year basis. It's above market growth is supported by new and ongoing product launches across the portfolio, price discipline and strong commercial execution.

We're excited about the year ahead with ongoing momentum across the region, particularly with our [indiscernible] portfolio, and further opportunity in our growth in emerging markets within the EMEA region. Asia Pacific grew 17% operationally versus Q4 in '19 versus the full year 2022, with all major markets growing strong double digits. Japan had a strong year, growing double digits for '22 with ongoing momentum from new products, most notably AGENT DCB [ resume ] POLAR FIT and WATCHMAN FLX, and a full year basis, China grew approximately 20% versus 2022. This consistent growth is fueled by the diverse portfolio, focus on innovation and strong commercial execution.

Looking ahead, we expect China to be an accretive mid-teens grower over our '24 to '26 LRP and to achieve over $1 billion in sales in 2024, supported by new product launches, supply chain agility and sustained investments in our talent and capabilities. The team in Latin America grew 17% operationally versus both Q4 full year '22 with 7 of 8 business units growing double digits on a full year basis.

I'll now provide some additional commentary on our BUs. Urology had an excellent quarter. 10% organic growth versus Q4 '22 and on a full year basis grew 11% organically. Full year growth was led by our Stone Management and Prosthetic Urology globally. And in 2023, we relaunched our direct-to-patient campaign, driving therapy awareness for erectile dysfunction and supporting double-digit growth within our prosthetic urology franchise. We're excited about the opportunities that Urology includes in our recently announced agreement to [ acquire ] Axonics, a medical technology company that offers innovative devices for urinary and bowel dysfunction. We look forward to bringing these commentary portfolios together and expanding access to differentiated technologies for physicians and patients.

Endoscopy sales were also excellent in the quarter, growing 12% operationally and 11% organically versus fourth quarter '22 and the full year basis growing 12% operationally and 11% organically. Within the quarter, strong results were led by AXIOS and single-use scopes, both growing double digits. On a full year basis, all regions grew double digits, supported by the broad and deep portfolio, new product innovation and focus on commercial excellence.

Neuromodulation sales grew 7% operationally and 3% organically versus fourth quarter '22 on a full year basis, 7% operationally and 5% organically versus '22. Our brain franchise grew double digits both in the quarter and on a full year basis, driven by the precise [ Genus ] portfolio and our innovative image-guided programming, which is designed to improve the precision and efficiency of the deep brain stimulation procedure.

In fourth quarter, on an organic basis, our pain franchise was flat year-over-year, which was in line with our expectations. We expect our performance to improve in 2024 and with the recent launch of our U.S. WaveWriter Alpha [ DPN ] indication and the strong real-world data on FAST recently presented at NANS. Furthermore, with the completion of our Relievant Medsystems acquisition in the fourth quarter, we're excited about our ability to offer expanded pain portfolio that supports a comprehensive treatment algorithm, now including the novel Intracept system for the treatment of chronic low back pain.

Peripheral Intervention sales were excellent also growing 12% operationally and 10% organically versus Q4 and a full year basis growing 13% operationally and 11% organically versus '22. Our [indiscernible] growth was led by the performance of our drug-eluting portfolio both in Q4 [indiscernible]. This market remains underpenetrated with more than half the procedures still being used with [indiscernible] metal devices, underscoring the importance of our ongoing commitment to innovation and clinical evidence.

In venous, Q4 [indiscernible] led by Varithena, our market-leading varicose vein technology. Additionally, in fourth quarter, [indiscernible] growth was supported by real PE, the largest real-world and near real-time data set evaluating advanced therapies for pulmonary embolism patients.

Our [ individual ] oncology franchise performed extremely well in fourth quarter and in 2023, growing low double digits with strength across our portfolio of robust embolization technologies and cancer therapies. We continue to look to expand our clinical evidence and are pleased to have commenced enrollment in the [ ROMAN ] trial, which will access the safety and efficacy of use TheraSphere in combination with immunotherapy, treat HCC, the most common type of primary liver cancer.

[ Cardiology ] delivered tremendous quarter -- delivered a tremendous fourth quarter and year, with both operational and organic sales growing 14% versus fourth quarter and for the full year 2022. Within Cardiology, Interventional Cardiology therapy sales grew 10% for the full year and -- for the quarter and its full year. On a full year basis, the coronary therapies franchise growth was driven by strong performance in our international regions and our imaging franchise globally. AGENT Drug-Coated Balloon continues to perform very well in Japan, and we now expect approval of the AGENT in the U.S. in the first half of 2024. AGENT DCB will be the first coronary drug-eluting balloon in the U.S. indicator for instant restenosis providing physicians and patient solution for this unmet clinical need.

Our structural heart valves franchise grew double digits in both fourth quarter and on a full year basis, led by the performance of ACURATE Neo2 in Europe, and we now have treated more than 70,000 patients to date with our ACURATE technology globally. As we look ahead, we anticipate approval of ACURATE Prime in Europe in 2025. However, after reviewing a planned interim analysis of the U.S. ACURATE IDE data, we will now wait for the full 1-year data from the RCT cohort of 1,500 patients to determine our regulatory strategy. Therefore, we no longer anticipate the approval of [ VacarPrime ] in the U.S. in 2024. Additionally, in alignment with the FDA, we are suspending enrollment in the single arm continued access study while continuing to enroll in the randomized extended durability cohort. We expect to have more information in the second half of 2024 following the full data review.

WATCHMAN sales grew 23% organically versus fourth quarter '22 and 25% on a full year basis. Q4 finished with record sales and strong utilization in major markets, we have now treated over 400,000 patients globally with the WATCHMAN technology. U.S. Q4 growth of 23% was supported by the breadth of the portfolio and the initial launch of WATCHMAN FLX Pro, which we expect to move into full launch in the first quarter. We continue to expand the breadth of clinical evidence supporting this technology and are pleased with the pace of enrollment within our post-market [ HEAL LAA ] trial, including our newly added cohort, which is studying in WATCHMAN FLX Pro and underrepresented patient populations.

We also look forward to initiating our monotherapy trial SIMPLIFY trial later this year, which will study WATCHMAN FLX Pro with a simplified post-implant drug regimen.

Cardiac Rhythm Management sales grew 5% organically versus Q4 '22 and on a full year basis grew 6% organically versus '22. On a full year basis, our Diagnostics franchise grew double digits, outpacing market growth driven by broad portfolio and ongoing investments in innovation. In core CRM, in both fourth quarter and on a full year basis, our high-voltage business grew low single digits and our low voltage business grew mid-single digits. 2023 performance was driven by our differentiated high-voltage portfolio and shock polarity options. As we look ahead, we expect our core CM growth to be in line with the market performance in '24.

Turning to Electrophysiology. Sales grew 43%, both operationally and organically versus fourth quarter '22 and the full year basis grew 37% operationally and 33% organically versus '22. U.S. fourth quarter sales grew 40% organically driven by our POLARx launch and ongoing win with our [ access ] solutions porfolio. Our international EP growth accelerated in the fourth quarter growing 46% organically, fueled by improved FARAPULSE console supply, and we now have treated over 40,000 patients globally with the FARAPULSE technology to date. And with the news this morning that we received FDA approval for FARAPULSE, we are thrilled to enter the U.S. market immediately.

We continue to invest in clinical evidence to study new indications and support access to our FARAPULSE technology. Late last year, we initiated the AVANT GUARD [indiscernible] to evaluate the safety and efficacy of the system as a first-line treatment for [indiscernible] in AF compared to antiarrhythmic drug therapy. Additionally, a real-world data was presented at AHA for more than 17,000 patients treated with FARAPULSE in the MANIFEST-17K [indiscernible] which reinforced the real-world safety profile of the [indiscernible] platform with no reports of permanent phrenic nerve [indiscernible] or pulmonary vein stenosis, or esophageal injury and an overall major event rate of less than 1%. We're excited to bring this innovative technology to more markets and expect approval of FARAPULSE in Japan -- China and Japan, likely in the second half of this year.

In closing, I'm very proud of our global team, what we are able to accomplish in '23, resulting in full year organic sales growth of 12% and adjusted EPS growth of 20%. We're excited about the year ahead and remain focused on our talent and sustaining the culture that's motivated to drive differentiated performance and achieve our long-range plan goals. Those goals as a reminder, are sales an average of 8% to 10% over the 3-year period while expanding adjusted operating margin by 150 basis points, including double-digit adjusted EPS growth and improvement of our free cash flow conversion to approximately 70% in 2026.

With all of that, I'll pass it over to Dan to provide more details on the financials.

[Daniel Brennan, executive]

Thanks, Mike.

Fourth quarter 2023 consolidated revenue of $3.725 billion represents 14.9% reported growth versus fourth quarter 2022 and includes a 40 basis point tailwind from foreign exchange, in line with our expectations. Excluding this $12 million tailwind from foreign exchange, operational revenue growth was 14.5% in the quarter. Sales from closed acquisitions and divestitures contributed 90 basis points resulting in 13.6% organic revenue growth, exceeding our guidance range of 8% to 10%.

Q4 2023 adjusted earnings per share of $0.55 grew 24% versus 2022, exceeding the high end of our guidance range of $0.49 to $0.52 primarily driven by our strong sales performance.

For the year 2023 consolidated revenue of $14.240 billion represents 12.3% reported revenue growth versus full year 2022 and includes an 80 basis point headwind from foreign exchange, again, in line with our expectations. Excluding this $104 million headwind from foreign exchange, operational revenue growth for the year was 13.1%. Sales from closed acquisitions and divestitures contributed 80 basis points resulting in 12.3% organic revenue growth, exceeding our guidance range of approximately 11%.

Full year 2023 adjusted earnings per share of $2.05 grew 20% versus 2022, exceeding the high end of our guidance range of $1.99 to $2.02. Adjusted gross margin for the fourth quarter was 70.4% resulting in full year 2023 adjusted gross margin of 70.7%, in line with our expectations and representing a 20 basis point improvement versus full year 2022, inclusive of a 220 basis point headwind from foreign exchange.

In 2024, we expect a mix benefit from our new launches with offsetting headwinds from FX and the incremental investment in our manufacturing capacity and as a result, we anticipate our full year 2024 adjusted gross margin will be at or slightly below our full year 2023 rate. Fourth quarter adjusted operating margin was 26.6% resulting in a full year 2023 adjusted operating margin of 26.3%, improving 70 basis points versus 2022. We expect to expand adjusted operating margin in 2024 by another 30 to 50 basis points balancing progress towards our long-range plan goal of 150 basis points over the 3 years 2024 to 2026 with flexibility for critical investments to support key launches.

On a GAAP basis, the fourth quarter operating margin was 15.7%, resulting in a full year reported operating margin of 16.5%.

Still below the line, fourth quarter adjusted interest and other expenses totaled $79 million, resulting in full year adjusted interest and other expense of $331 million, in line with our expectations. On an adjusted basis, our tax rate for the fourth quarter was 10% and [ 11.2% ] of the full year 2023, including favorable discrete tax items and the benefit from stock compensation accounting. Our operational tax rate was 14.6% for the fourth quarter and 13.9% for the full year, again, in line with expectations.

Fully diluted weighted average shares outstanding ended at 1.477 billion shares in Q4 and 1.464 billion shares for full year 2023. Free cash flow for the quarter was $718 million, with $984 million from operating activities, less $267 million of net capital expenditures. Excluding special items, adjusted free cash flow was $913 million. Full year 2023 cash flow was $1.8 billion, and adjusted free cash flow was $2.5 billion both in line with expectations.

For 2024, we expect full year free cash flow to be in excess of $2 billion, which includes approximately $800 million of expected payments related to acquisitions, restructuring, litigation and other special items. As of December 31, 2023, we had cash on hand of $865 million and our gross debt leverage was 2.3x. We expect to fund the Axonics acquisition through a mix of cash on hand and new debt, which will be determined prior to or at the time of close. Our top capital allocation priority remains strategic tuck-in M&A followed by annual share repurchases to offset dilution from employee stock grants.

Our legal reserve was $377 million as of December 31, a decrease of $30 million versus the prior quarter $108 million of this reserve is already funded through our qualified settlement funds.

Now I'll walk through guidance for the first quarter and the full year 2024. We expect full year 2024 reported revenue growth to be in a range of 8.5% to 9.5% versus 2023, excluding an approximate 50 basis point headwind from foreign exchange, based on current rates, we expect full year 2024 operational revenue growth to be 9% to 10%, excluding a 100 basis point contribution from closed acquisitions, we expect full year 2024 organic revenue growth to be in a range of 8% to 9% versus 2023. We expect first quarter 2024 reported revenue growth to be in a range of 7.5% to 9.5% versus first quarter 2023, excluding an approximate 100 basis point headwind from foreign exchange based on current rates, we expect first quarter 2024 operational growth to be 8.5% to 10.5%, excluding a 150 basis point contribution from closed acquisitions, we expect first quarter 2024 organic revenue growth to be in a range of 7% to 9% versus Q1 2023. We expect our full year 2024 adjusted below-the-line expenses to be approximately $330 million.

Under current legislation, including enacted laws and issued guidance under OECD Pillar 2 rules, we forecast a full year 2024 operational tax rate of approximately 14% and an adjusted tax rate of approximately 13%. We continue to monitor tax legislation globally, including the currently drafted law to partially repeal U.S. R&D capitalization. The law were to be passed as currently proposed we would expect a tailwind of approximately 100 basis points to our operational tax rate in 2024.

We expect full year adjusted earnings per share to be in a range of $2.23 to $2.27 representing 9% to 11% growth versus 2023, including an approximate $0.04 headwind from foreign exchange at current rates and existing hedging contracts, which will be recognized ratably through the year. We expect first quarter adjusted earnings per share to be in a range of $0.50 to $0.52.

For more information, please check our Investor Relations website for Q4 2023 financial and operational highlights which outlines more details on Q4 and full year results and 2024 guidance.

In closing, I'm very proud of our 2023 performance and look forward to executing on our 2024 guidance of 8% to 9% organic revenue growth, 30 to 50 basis points of adjusted operating margin expansion and adjusted EPS growth of 9% to 11%.

Before I turn it back over to Lauren for the Q&A, I wanted to provide a quick update. A key part of our talent strategy is moving high potential individuals throughout the company to give them a broad set of experiences. As part of this, effective March 1, Lauren Tengler will become the Global Controller for our Urology business unit providing financial leadership to the global business and importantly, playing a key role in the integration of the Axonics business. Lauren previously spent many years within our Urology business, making her uniquely qualified for this opportunity.

Following Lauren's transition, [ John Monson ], currently our Chief Accounting Officer, will move to our Investor Relations function, leading [indiscernible] and the rest of the team. I know the investment community will join me in thanking Lauren for her leadership and contributions and in welcoming John to the role.

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

[Lauren Tengler, executive]

Thanks so much, Dan. Drew, let's open it up to questions for the next 30 minutes or so. In order for us to take as many questions as possible, please let yourself to 1 question. Drew, please go ahead.

[Operator]

[Operator Instructions] The first question comes from Robbie Marcus with JPMorgan.

[Robert Marcus, analyst]

Congrats on a really good quarter. And congratulations, Lauren, on the promotion. Wanted to ask on 2 of the biggest product drivers in 2024 WATCHMAN and FARAPULSE. FARAPULSE got approval today. Wanted to see what's included in guidance for this year? And how to think about phasing over the year? How long will it take to get into hospitals and approved on formularies?

And then second on WATCHMAN, it look -- still had a very good quarter in fourth quarter, but growth slowed a little bit. How should we be thinking about the potential for WATCHMAN and 20% plus growth in 2024?

[Michael Mahoney, executive]

Sure. Thanks, Rob, for the comments. I'll start with WATCHMAN. It's just an excellent platform. It [indiscernible] growth of 23% for the quarter, 25% for the full year, terrific work. And as you know, that product gets larger and larger for us. I had to cut the script back because the clinical investments we're making with WATCHMAN go on for a while, and we can touch on those if interested. But as you know, we continue to exceed likely 90% share in the U.S. We'll be rolling out WATCHMAN FLX Pro, more as a percent of our total mix in the U.S. in the first quarter and throughout the year. So you continue to see that, which is a differentiated platform. So clinical work that we're doing and the WATCHMAN FLX Pro and the durable sheet is likely to be in the market in 2024 as well. We continue to expect to gain share, and we aim to significantly widen the market opportunity through this clinical trial. So full steam ahead with WATCHMAN.

On FARAPULSE, maybe the most exciting day I've had in my career, Boston Scientific with this platform that we have based on the results that we've seen in Europe and the enthusiasm globally for our PFA platform and to receive approval today was really exciting. We did anticipate a first quarter approval for FARAPULSE. And as you might expect, we expect to impact FARAPULSE to be somewhat in the first quarter and much more significant as the year goes on as we work with contracting with hospitals, getting on contract and getting the capital approved and rolling it out but we have a lot of experience in doing that. Our European success that we've enjoyed. Our team is trained. We have installation team. We continue to invest in it. So we're really excited about aiming to disrupt the EP market with what we think is the premier PFA platform.

[Operator]

The next question comes from Joanne Wuensch with Citi.

[Joanne Wuensch, analyst]

I don't want to leave FARAPULSE quite yet, and I suspect there will be a lot of questions on it this call. But if you're looking for China and Japan approval in the second half of '24, could you sort of outline what you think those opportunities may be?

And then can you just give a quick highlight on some of the sort of higher profile cardiology companies such as POLAR and AGENT?

[Michael Mahoney, executive]

Yes. So, Ken can help me out. But obviously, China and Japan represent significant opportunities in the EP market. They're the largest markets that we compete in, in those countries, and we currently are under scale, particularly in China. In Japan, we've built a lot of momentum over the last, call it, 18 months with our POLARx launch. So in Japan, that grew, I don't know, I think over 40% our EP business. And so we have a more scaled commercial team capabilities in Japan and the eventual approval in the second half of this year in Japan with FARAPULSE will really be the next leg of the growth stool in Japan for us.

So a lot of confidence there, that market in China may be even bigger. We're a bit more underscaled in China. So we'll be making a lot of investments there. We have a brand-new leader. We're excited about in China. It's around our EP business under June Chang, so we'll be making additional commercial investments, clinical investments and hope to have approval in the second half of the year in China. So those will be nice growth drivers for us in '24 more significant in 2025.

And AGENT, Ken, do you want to comment a bit more on FARAPULSE?

[Ken Stein, executive]

I'd love to comment on FARAPULSE, Again, it is a very exciting day. Joanne, in terms of questions specifically about Japan and China, right? I think we got to realize, I mean, AFib is a global disease. I hate to use the word pandemic, but it is pandemic. Now -- and we're really pleased about the strength of the clinical trial data that we have as well as the commercial experience in Europe with, as Mike said, greater than 40,000 patients already treated to date. And it's that strength of the clinical data, right, that led us to the really, I think, rapid approval that we got from the FDA and that has led us to update our anticipated approval times, both in Japan and China. Again, I think having said that, we look to those approvals in the second half. So I don't think we're going to expect to really see too much material out of that until we get into 2025, but they are both large and important markets and large and important patient populations that are currently really very much underserved in terms of access to ablation technology.

[Operator]

The next question comes from Larry Biegelsen with Wells Fargo.

[Larry Biegelsen, analyst]

Congrats on a strong finish here and the approval of FARAPULSE in the U.S. On FARAPULSE, can you talk about the manufacturing capacity for the catheter and console upon launch?

And expectations for the EP business this year, you grew 43% in Q4 '23. Any reason why growth would be lower in '24?

And I have to ask you to please clarify your comments around ACURATE Neo2, it sounds like something happened with Prime, which is the larger size, what are the implications for the other sizes of Neo2 in Europe and the U.S.?

[Michael Mahoney, executive]

Thanks, Larry. Starting with FARAPULSE. Really very proud of the global supply chain team and what they've done over the past 18 months in the FARAPULSE group that we recently acquired a while ago but they've done a tremendous building the capabilities to supply this for the U.S. launch and to expand in Europe and eventually Asia, as we just highlighted. We are now significantly improved our catheter -- catheter and console supply. We opened numerous centers in Europe in the fourth quarter and we're ready to go. So we, at this point, don't anticipate supply being an issue to continue to support Europe or to facilitate the U.S. launch, given the capabilities and investments that we've made and approvals to manufacture in multiple locations. So great work by the supply chain team, and we're ready to launch this in the U.S.

On ACURATE Neo2, as I mentioned in the earnings script, maybe just 2 overall points, we continue to do very well with ACURATE Neo2 in Europe. Implanting, I think the number is 70,000 and continue to grow faster than the market in Europe. And we are on track for what we have is called Prime in Europe in 2025. So that continues to move forward as planned.

With respect to the trial, as I mentioned in the script, based on the interim analysis, we now need to wait for the full 1-year follow-up of 1,500 patients. And as a result of that, we don't -- we will not be receiving approval for ACURATE Neo in 2024, and we will wait until likely near the end of 2024 for the full readout of the ACURATE IDE study to determine our path forward.

[Operator]

The next question comes from Vijay Kumar with Evercore ISI.

[Vijay Kumar, analyst]

Congrats on a really strong finish year. Maybe just one on the guidance here, perhaps for Dan. Dan, the 8% to 9%, it looks like FARAPULSE, the prior guide assumed a back half launch. It's coming in a little bit ahead. Can you just walk us through that 8% to 9%? Is that right that FARAPULSE perhaps assumptions have changed? Any impact from [ BBP ] or [indiscernible] we should be aware of? And what are you assuming for pricing in fiscal '24?

[Daniel Brennan, executive]

Sure. So the [ VBP ] assumptions are the same as they've always been, really no change there. As you saw in December when we issued the press release on AVANT GUARD, we moved up the timing of expected FARAPULSE launch to Q1. So we've been anticipating Q1 launch and that 8% to 9% full year and the 7% to 9% for the first quarter in terms of revenue growth contemplated a Q1 approval of FARAPULSE. As Mike said, there's probably some contribution in Q1, but more of that contribution comes in Q2 to Q4. So the 8% to 9% has that -- has contemplated in the overall guide.

And then pricing. So what I would say on pricing is we were basically flat in 2023 and the goal is to be flat again in 2024. So likely no impact would be the goal in 2024 versus 2023.

[Vijay Kumar, analyst]

Sorry, on days, Dan. Any days impact here?

[Daniel Brennan, executive]

No, all the days, there's a lot of -- obviously, a lot of noise and days around the world through the year. It's all contemplated in guidance, all in the 8% to 9% for the full year.

[Operator]

The next question comes from Danielle Antalffy with UBS.

[Danielle Antalffy, analyst]

Just a follow-up question on ACURATE Neo2, Mike, if I could. So appreciate the comments that you did provide. Just curious, I mean, obviously, you're giving pretty strong guidance here for 2024. I mean is the right read here that regardless of what happens with ACURATE Neo2 and timing there, you're sticking to your long-term sales growth guidance that you provide?

[Michael Mahoney, executive]

Okay. We'll.

[Lauren Tengler, executive]

I'll work my way in.

[Michael Mahoney, executive]

Once in a while. We're excited for John to come in and Lauren to move out. Excited for Lauren to go to Urology.

Yes. So to answer your question, we are fully committed to the 8% to 10% organic growth CAGR over the '24 to '26 period that we provided at Investor Day, absolutely no change in that outlook and pleased with the '23 performance, as you know, where we grew 12%. So absolutely no change to those financial goals.

ACURATE continues to do well in Europe. It's a product that's used every day by many European physicians, and we're excited about getting the larger size approved there. We are disappointed that we didn't get accurate over the [ Goldline ] for approval in 2024. So at this point, we need to wait until the full data sets followed up for a year and read out likely for the end of this year in 2024, and we'll take it from there in terms of the U.S. launch. But we are disappointed we're not going to launch that really very end of this year and into the next but absolutely no change to our financial guidance that we gave at Investor Day.

[Danielle Antalffy, analyst]

Okay. Great. And also welcome, John. Sorry, I did mean to leave you out.

[Operator]

The next question comes from Travis Steed with Bank of America.

[Travis Steed, analyst]

Maybe one more follow-up on TAVR. Could you remind us what the interim look was? Was that just like a 6-month look at the data, now you need to wait for a 1-year data for the line to separate? I'm curious if you think what you saw in the interim look, are you still pretty confident that at 1 year, we could have a U.S. TAVR launch? Or does this put the whole U.S. TAVR launch at risk?

[Michael Mahoney, executive]

Are you able to hear us okay?

[Travis Steed, analyst]

Yes, I can hear you loud and clear.

[Michael Mahoney, executive]

Great. Dr. Sathananthan is our Chief Medical Officer, as you know, for [ ICT X ] and Structural Heart, maybe you could comment a bit.

[Janar Sathananthan, executive]

Yes, I'll take the comment just about the data. So essentially, what happened in the trial was that as part of a planned interim analysis, we made the decision to await the full 1-year data. It is important just to note that the ACURATE IDE study is still an active clinical study with active clinical follow-up. And so as a result, we cannot disclose any data related to the trial at this time. We will expect, as Mike said, a readout study in the second half of 2024 following a full data review.

[Operator]

The next question comes from Josh Jennings with TD Cowen.

[Joshua Jennings, analyst]

Congratulations for a strong end of the year. I wanted to ask about the international cardiac ablation market. Boston incredible fourth quarter, 40-plus percent growth, some of your competitors delivered really strong international growth in their electrophysiology businesses as well. What's going on in the international market? I mean are we seeing the promise of PFA driving market expansion this early? Or is there any pricing dynamics going on, but I think it's 20% almost market growth in internationally for cardiac ablation this year. Just wanted to get some details there and whether that could translate to PFA launches in the United States driving market expansion, which I think you guys have detailed in your Investor Day?

[Michael Mahoney, executive]

Dr. Stein, do you want to take a shot at it?

[Ken Stein, executive]

Yes, Josh. And thanks, Mike. I think it's a couple of factors here. And I don't think it's -- I don't know that I can parse out for you how much is getting contributed from each. But again, I think we just begin with the fact, right, that atrial fibrillation is an incredibly common arrhythmia. Again, as I said earlier, it is literally pandemic worldwide. I know, for instance, in the U.S., right, 1/4 of adults over the age of 40 will experience AFib at things for us like StablePoint or POLARx is incredibly effective. It's more effective in drugs -- but on a global scale, it is still really incredibly underpenetrated as a market. And much of the growth that you see really just reflects, I think, increasing realization in the cardiology community, the referring physician community about the relative efficacy and safety of all ablation technologies.

And then you layer on top of that the promise and the data with FARAPULSE, right? And FARAPULSE takes a procedure that's already effective. It is at least as effective, it is clearly safer. And it's also much more efficient than thermal ablation. And so that enables docs and medical centers to scale this out much better, right? And start to get into this underpenetrated population.

So maybe a long-winded answer, but the short answer is, it's both a dramatically underpenetrated population to begin with. And then on top of that, you have the accelerated impact of FARAPULSE.

[Operator]

The next question comes from Richard Newitter with Truist Securities.

[Richard Newitter, analyst]

Congrats on a really strong finish to the year. My first question is just going back to TAVR. At your Analyst Day, you had talked to an expectation and the level of confidence that you could disrupt that market in the U.S. relatively quickly out of the gate. I'm just curious with -- I guess something approaching 20% share of the market over time, which is what you've done in other markets with your disruption capabilities. I'm just curious, does anything change there with the indeterminate kind of view of what the next steps are for the U.S.? I'm just trying to focus on that commentary a bit. Does your outlook for the franchise in the U.S. change in TAVR? And then I have a follow-up.

[Michael Mahoney, executive]

Yes. Just a few clarifying points. Again, in Europe, where, we set 70,000 valves and physicians use it routinely on an everyday basis. we Continue to grow faster than the market there and have continued to done that for, I don't know, 10 quarters in a row. So we make nice progress, and we're excited about getting the large valve size approved in Europe. I believe 2025 is the time period.

In the U.S., honestly, we -- first of all, I would state that we've never quoted a market share goal for TAVR in the U.S. So we never set 20%, I'm not sure if that was what you put in your models or not. But based on the results that we've seen in Europe, we've always been confident in our ability to have ACURATE be a meaningful growth driver in the U.S. as we stated at Investor Day.

As a result of this, we are disappointed that we're not going to have this launched in 2024, as we talked about based on the data that we just highlighted in the script, and as Janar mentioned, we now need to wait for the full year data, the full 1-year follow-up on the 1,500 patients and then working with the FDA and submitting that and having that data read out by year-end and we'll take it from there.

So we -- as Janar said, the trial is still active. So we do not expect any of this news to alter our 8% to 10% organic growth over the 3-year period, we're coming off 12%. We continue to grow faster than most all of our peers and drop EPS faster than our peer group. And we're still very committed to those financial targets. And we're hopeful that ACURATE will continue to be a big growth driver for us, but a lot of it depends on that data readout in fourth quarter.

[Richard Newitter, analyst]

Okay. And then maybe just on M&A, you've been active in 2023, and congrats on Relievant and more recently Axonics early this year. I'm just curious on kind of how we should think about how aggressive and opportunistic will be over the next 12 months? You mentioned, obviously, your first priority remains, deploying capital for tuck-ins but do we kind of think of you guys in a little bit of a digestion period or kind of steady as she goes, just as aggressive and opportunistic as you have been in the past?

[Daniel Brennan, executive]

Sure. I can take that one. So as you mentioned, Axonics, the most recent deal we did, super pleased with that. I think that is a classic tuck-in for Boston Scientific. It's -- it's one I think -- as you look back, these types of deals, we really do well with, and we're super excited to have that close and welcome the Axonics team into the BSE family.

As I said, we've been remarkably consistent over a long period of time. Tuck-in M&A is still the #1 capital allocation priority for us, and we'll continue to be active. In terms of the -- how active over the near to medium term, this is not a major event like a major delevering event that we need to do. This is take on a little bit of additional debt over a period of time and then over a very reasonable period of time. We'll be right back to where we are today relative to our leverage goals. So I'd look for us to continue to be active in the tuck-in M&A space in '24 and beyond.

[Richard Newitter, analyst]

Okay. Again, congrats on an outstanding 4Q.

[Operator]

The next question comes from Patrick Wood with Morgan Stanley.

[Patrick Wood, analyst]

Congrats, Lauren. I'd like to stick with Axonics, if that's right. I appreciate it hasn't closed yet. But I'm just kind of curious, Urology in Boston has a very sizable distribution network across, I guess, primarily Stone Management, but a whole bunch of different areas. How are you thinking about the ability to drive adoption in OAB faster and like really push that asset? I'm guessing having just played with the numbers and correct me if I'm wrong, but some assumption of slightly faster growth once you've acquired Axonics [ Sandy Street ] previously had in there, at least that's where I end up with the numbers, feel free to correct me, but how are you thinking about the commonalization and really pushing that through the distribution network?

[Michael Mahoney, executive]

Sure. Well, we haven't closed it yet. We hope to first half of this year. The team at Axonics has done an amazing job with this platform since starting the company years ago and taking significant share in what is a strong double-digit growth market. The team at Axonics can't speak too much for them, it hasn't closed yet. As [indiscernible] done a remarkable job in a few areas, one of just the core technology where they gained -- leverage that to gain share. The clinical data that they have, the commercial excellence that they possess and also expanding the market through their direct-to-patient marketing and awareness. So this is a significant global opportunity and the patient awareness of this treatment is still early days. And so that's one reason why we acquired the company was the momentum they have, the technology and the long-term market CAGR that we see based on the global opportunity.

The market today is nearly all U.S. That's something we'll evaluate more in the future here as to would it make sense for us to bring this to select markets outside the U.S. given the data that we have.

As you mentioned, we have a significant commercial channel in our Urology business through all of our different business units within Urology. So this is an ideal fit. It is an adjacency for us. We don't have any competitive product in this area. So it's a nice adjacency force that will allow us to compete more competently with Urology customers. But we aim to take Axonics is to the next level, but that team has done a terrific job to date.

[Operator]

And just to verify, do we have time for one more question?

[Lauren Tengler, executive]

Yes. One last question please.

[Operator]

That question will come from Michael Polark with Wolfe Research.

[Michael Polark, analyst]

I'll ask a gross margin question. Dan, I heard in the script for '24 flat to maybe slightly down year-on-year in the guide. The world seems to be calmer on price cost. But as we all know, the Middle East is flaring. And so I'm curious, one, have you built in any cushion for kind of cost push from those events? And two, in real time, are you seeing any impact in the field? And if so, what does that look like?

[Daniel Brennan, executive]

Yes, I can give you the short answer and a little bit longer answer. So the short one is that we've contemplated all that. Our team is super close to everything relative to our global supply chain network. And so there everything that we have in the guidance that we gave contemplates what we know today and what -- and the guidance that they're giving us on that, which the impact is minimal.

Overall, on gross margin, a little bit longer answer. If you look at '23, we came in pretty much right where we expected at that 70.7%. And then as we said at the Investor Day in September, we said it would be a challenge to contribute to our margin expansion goals in '24, right, which that's probably going to prove out to be true. The thing will be either as slightly below. But that's okay. There are many other areas of the P&L. And as you know, we have a pretty solid track record over time of managing all those lines of the P&L to drive most recently, that's 70 basis points last year.

So for '24, I'd kind of point to 2 headwinds and 2 tailwinds that will that will play out and again, have us at that kind of at or slightly below the 70.7% we put up last year. And one is inflation. And that's probably a little bit of a tailwind, right? So it's -- the macro factors are improving in general relative to inflation and other things. But as a reminder, we enter into contracts for many elements of materials for '24 already last year. So we don't want to see that full benefit. But in '25 and '26, I'd like to believe there's even more benefit there, not only from the macro side of inflation, but also for gross margin in total.

And then our mix. So getting the FARAPULSE approval today, that's exciting because that's a great mix thing for the company and many of our other launches are as well. And then on the headwind side, foreign exchange was a headwind in '23 continue in '24. And as I said at Investor Day, a good problem to have, but we also need to make investments in manufacturing [indiscernible] to support the sales growth, growing 12% last year and then 8% to 9% this year. But we're absolutely committed to the 150 basis points over 3 years. Gross margin probably won't pay a lot of bills for us in '24 but I think it certainly will in '25 and '26. Recall, we used to be north of 72% back in 2019, and we are maniacally focused to get there. And then to get the overall operating margin kind of on the doorstep of '28 when we get to 2026 and that puts that 30% long-term goal that we've had kind of right in our line of sight as we're in 2026.

[Lauren Tengler, executive]

Thanks for joining us today. We appreciate your interest in Boston Scientific. If we were unable to get to your question or if you have any follow-ups, please don't hesitate to reach out to the Investor Relations team.

Before you disconnect, Drew will give you all of the pertinent details for replay.

[Operator]

Thank you. Please note, a recording will be available in 1 hour by dialing either 1 877 344 7529 or 1 412 317 0088 using replay code 239 4361 until February 7, 2024, at 11:59 p.m. Eastern Time.

The conference has now concluded. Thank you for attending today's presentation. You may now disconnect.