Boston Scientific (BSX) Q3 2019 Earnings Call Transcript

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Boston Scientific (NYSE: BSX)
Q3 2019 Earnings Call
Oct 23, 2019, 8:00 a.m. ET


  • Prepared Remarks
  • Questions and Answers
  • Call Participants

Prepared Remarks:


Ladies and gentlemen, thank you for standing by, and welcome to the Boston Scientific Q3 2019earnings call [Operator instructions] As a reminder, today's call is being recorded. I will now turn the call over to your host, Susan Lisa. Please go ahead.

Susan Lisa -- Vice President, Investor Relations

Thanks, Kevin. Good morning, everyone, and thanks for joining us. 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 Q3 2019 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 & Filings. The duration of this morning's call will be approximately 1 hour. Mike will provide strategic and revenue highlights of Q3 '19. Dan will review the financials for the quarter and then provide Q4 '19 and full-year 2019 guidance, and then we'll take your questions.

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During today's Q&A session, Mike and Dan will be joined by our chief medical officers, Dr. Ian Meredith and Dr. Ken Stein. Before we begin, I'd like to remind everyone that, on the call, operational revenue excludes the impact of foreign currency fluctuations, and organic revenue further excludes the impact of certain acquisitions, including NxThera, Claret, Augmenix, Vertiflex and BTG in the relevant periods for which there are no prior period-related net sales.

Also of note, this call contains forward-looking statements within the meaning of federal securities laws, which may be identified by words like anticipate, expect, believe, estimate, and other similar words. They include, among other things, statements about our growth and market share; new product approvals and launches; clinical trials; cost savings and growth opportunities; our cash flow and expected use; our financial performance, including sales, margins, earnings and other Q4 and full-year 2019 guidance; as well as our tax rates, R&D spend, and other expenses. Actual results may differ materially from those discussed in the forward-looking statements. Factors that may cause such differences include those 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 for his comments. Mike?

Mike Mahoney -- Chairman and Chief Executive Officer

Thank you, Susie. Good morning, everyone. Boston Scientific delivered a very strong third quarter. We continue to grow above market and improve profitability while we also invest for the long term and deliver meaningful innovation to address unmet patient needs.

In the third quarter, our team delivered 14.2% operational and 9.3% organic revenue growth with another quarter of strong balance across our businesses and geographic regions. In addition, we delivered adjusted EPS of $0.39, which is the high end of our guidance range, while generating $526 million in adjusted free cash flow. We're also narrowing our guidance for the full-year 2019 organic revenue growth to approximately 7.5% and bringing up the bottom end of our adjusted EPS guidance range to $1.55 to $1.58. We've also increased our expected contribution from acquisitions from 140 basis points to 360 basis points, resulting in operational revenue growth guidance of 11% to 11.5% for the full year.

I'll now detail some key aspects of our third-quarter results and thoughts on our Q4 '19 prospects. All growth rates refer to organic sales growth versus the prior year unless otherwise stated. MedSurg sales accelerated to 10% organic and 14% operational revenue growth. Endoscopy organic revenue growth of 10% was fueled by the breadth of our portfolio, including multiple launches across several franchises, most notably in infection prevention, therapeutic imaging, biliary, endoluminal, and hemostasis product lines.

We also enjoyed double-digit growth across multiple regions. And importantly, we remain on track for year-end launch of our Exalt-D single-use duodenoscope. And we're encouraged by the FDA's communication in September regarding single-use technologies. We continue to believe that our therapeutic imaging portfolio represents a significant opportunity in 2020 and beyond with an incremental $2 billion market opportunity by 2024.

Urology and pelvic health also grew 10% organically and 19% operationally. And I would say this is particularly impressive as the team offset 150-basis-point headwind to organic growth from the market withdrawal of transvaginal mesh for the treatment of pelvic organ prolapse. Double-digit growth organic sales in UroPH was led by strong momentum in our core stone, where we are uniquely positioned to treat the broadest range of kidney stone cases via our innovative LithoVue, lithotripsy and laser portfolio. SpaceOAR, which is a hydrogel that temporarily creates space between the prostate and organs at risk during radiotherapy for prostate cancer, contributed 900 basis points of operational revenue growth and went organic in October 1st.

SpaceOAR continues to deliver excellent results and is tracking to $100 million for full-year '19. In the quarter, NxThera, which offers a unique minimally invasive treatment for BPH, also accelerated our growth. We continue to engage with insurers, physicians and patients to strengthen this exciting platform. Our rhythm and neuro team grew 4% in the quarter, which we believe represents above-market growth in CRM at 2% while EP sales did grow below market at 7% and neuromodulation sales grew 8%.

So I'll start off with neuromodulation. The neuromodulation sales results of 8% organic and, what was it, 18% operational growth represents an acceleration versus second quarter despite a challenging 23% comp in Q3 2018. In our neuromodulation business, we have developed a strong and diversified portfolio in deep brain stimulation and across the continuum of care for pain patients via our complementary platforms in SCS, RF and Vertiflex. In DBS, our Vercise platform nearly doubled sales year over year and is consistently gainingglobal marketshare and now offers patients full-body MRI labeling along with our differentiated Cartesia Directional Lead.

In our pain franchise, our SCS results, which were down low single digits globally, showed sequential improvement as we're seeing some modest signs of market stabilization. We aim to deliver continued improvement in SCS in fourth quarter with the launch of WaveWriter software enhancements and then into 2020 with the release of the Combo randomized clinical trial data and WaveWriter at NANS in January. The Vertiflex platform represents an important therapy for patients with moderate lumbar stenosis. Vertiflex continues to see growing demand and is on track to deliver full-year 2019 sales of $60 million.

And overall, we're enjoying strong momentum with our category leadership strategy across our neuromodulation portfolio. Global CRM sales grew 2%. And in defib, global sales continued to grow faster than market and were up low single digits, driven by our Resonate platform and replacements, while S-ICD sales also continued to grow. Pacer sales declined low single digits in the quarter, which were consistent with second quarter, but we're wrapping up the limited U.S.

market release of our new program, which should enable an improved implant experience and unique remote service capabilities. So looking ahead, we remain on track to launch LUX-DX, which is our implantable cardiac monitor, by mid-year 2020. EP sales grew globally 7%, but importantly, we received U.S. IDE approval in late September to begin the clinical trial of our POLARx single-shot cryotherapy, and we plan to initiate enrollment before year end.

We're targeting the year-end launch of POLARx in Europe and excited to enter this large, fast-growing single-shot market with this next-gen cryo platform. Shifting now to cardiovascular. Group sales were up a strong 13%. Peripheral interventions sales increased 8%, led by continued momentum across our arterial, venous and interventional oncology platforms.

The launch of our Vici Venous Stent is going very well, and global Eluvia results were consistent with our previous commentary at TCT in September. On August 19, we closed the BTG transaction and welcomed the team to Boston Scientific. Sales of legacy BTG interventional grew high single digit in third quarter, and we're very pleased with the integration process thus far and expect this business to deliver double-digit growth in 2020. We're focused on adding additional commercial capabilities, initiating product registrations in Europe and Asia and delivering productivity synergies as previously communicated.

Specialty pharma sales declined in the quarter largely due to rebates and timing of product expirations, yet we're slightly above our internal plan as CroFab continues to do well both clinically and in maintaining high market share. For the third quarter stub period, which is August 19th through September 30th, all of BTG is reported separately for both sales and operating income as we integrate our operating and reportable segments. Our interventional cardiology business accelerated from 5% in first quarter to 8% in second quarter and now 15% in third quarter. This represents strong growth across all regions, led by structural heart sales across all product lines.

And excellent growth in coronary therapy is up 6% globally. The diversification of our coronary therapies business continues to deliver results with mid-teens growth across the board in complex PCI products while our PCI guidance business, which is IVUS and FFR, grew in the mid-20s. Drug-eluting stent sales were down mid-single digits, which is an improvement from first-half trends. And in Europe, we recently launched Synergy Megatron, which is a purpose-built stent for large proximal vessels.

With the mid-2020 U.S. launch targeted, Megatron is an important extension of our market-leading Synergy platform.With respect to our DES business, I'd like to comment on some recent concerns regarding the potential impact of the ischemia trial, which is scheduled to be presented at AHA on November 16. We won't know the results on ischemia until then, but we believe the impact will be highly manageable in all scenarios with the potential future dollar impact ranging from slightly positive to negative $40 million. So I'll leave additional details on this topic for any interest in Q&A, where Ian can provide more detailed commentary about the trial design and physician practice.

So now turning to structural heart. The combined strength of Watchman, Lotus Edge, Acurate and Sentinel position us very well to deliver toward the high end of our guidance of $700 million to $725 million in structural heart revenue in 2019. Watchman year-over-year growth accelerated from second quarter's rate as the platform continues to build global momentum with physicians and patients. And Watchman recently received reimbursement in Japan, and we're building up this new therapy with a focus on opening new accounts and physician training.

We continue to enjoy strong demand for next-generation Watchman FLX in Europe, and we're enrolling both in the Option trial, as well as the ASAP-TOO. The U.S. reimbursement outlook for Watchman remains very positive with an 8.6% weighted average increase in 2020 Medicare reimbursement. So turning to our TAVR business.

Acurate neo sales grew faster than the market in third quarter, and that product is now available in 45 countries. We continue to enroll in Acurate neo2 IDE trial in the U.S. with a targeted 2021 launch, and we also continue to expect European launch of our next-generation Acurate valve in mid-2020. And post the SCOPE1 results and prior to the launch of Acurate neo2 in Europe, we do estimate that Acurate neo growth will likely slow on a percentage basis but will likely remain accretive to both -- growth for both IC and BSC overall.

The Lotus Edge launch is going extremely well, and we're building momentum in both the U.S. and Europe. We remain on path -- on pace to open 150 accounts in our first 12 months in the U.S., and we're currently in a limited market release for the 15 French iSleeve introducer sheath. We also remain on track to launch in Japan in 2020 and continue to enroll the Reprise IV U.S.

clinical trial to expand indication to intermediate-risk patients. Finally, adoption of the Sentinel cerebral embolic protection device continues as penetration and account openings expand in the U.S., Europe and other markets. Sentinel is now in 500 accounts globally, and we're pleased to announce recently at TCT that, in 2020, we will initiate the global Protected TAVR randomized clinical trial. We believe that definitive evidence focused on a stroke endpoint will continue to elevate Sentinel to become the standard of care for all patients and will help influence future clinical guidelines.

So to close, I'd like to share my enthusiasm for the outlook on the rest of this year and in 2020 and beyond. We believe that Boston Scientific continues to be uniquely positioned to drive shareholder value due to our strong long-term growth profile, meaningful opportunity to improve operating margins, track record of delivering double-digit adjusted EPS growth and our proven ability to deploy capital. I want to really thank our employees once again for their winning spirit and commitment to advancing science for life. And Dan will now provide a detailed review of our financials.

Dan Brennan -- Executive Vice President and Chief Financial Officer

Thanks, Mike. Third-quarter consolidated revenue of $2.707 billion represents 13.1% reported revenue growth and reflects a $26 million headwind from foreign exchange, slightly favorable to the $30 million to $35 million headwind expected at the time of guidance. On an operational basis, which excludes the impact of foreign currency fluctuations, revenue growth was 14.2% in the quarter. Sales from the Claret, Augmenix and Vertiflex acquisitions contributed 210 basis points, higher than the 180 basis points expected at the time of guidance.

As a reminder, the operational contribution from Claret only represents one month as the acquisition was considered organic as of August 1 this year. The acquisition of BTG, which closed within the quarter and was not included in prior guidance, contributed an additional 300 basis points to operational growth with two-thirds from the interventional medicine business and the remainder in specialty pharmaceuticals. The divestiture of our legacy embolic beads portfolio partially offset acquisition contributions by 10 basis points. The resulting organic growth of 9.3% in the third quarter exceeded our guidance range of 7.5% to 9%.

With this strong sales performance, we delivered Q3 adjusted earnings per share of $0.39, at the high end of our guidance range of $0.37 to $0.39 and representing 13% growth versus the prior year. The FX impact on adjusted earnings per share was immaterial as expected at the time of guidance. Adjusted gross margin for the third quarter was 72.7%, at the midpoint of our guidance range of 72.5% to 73% and flat versus prior year as favorable FX impact and manufacturing improvements were offset by price erosion in coronary drug-eluting stents and pacers, as well as a mix shift within our coronary therapies franchise from DES to complex PCI products. Adjusted SG&A expenses were $949 million or 35.1% of sales in Q3, a 40 basis point improvement year over year due to ongoing operating expense control and optimization initiatives but just outside our guidance range, driven by the acquisition of BTG, which was not included in guidance since the transaction had not closed at the time.

Adjusted research and development expenses were $297 million in the third quarter or 11% of sales, at the high end of our range, again partially driven by BTG expenses which were not reflected in guidance; and relatively flat to Q3 of last year. Royalty expense was 0.6% of sales, also roughly flat over prior year. With solid top-line results balanced by the funding of key commercial launches and supporting acquisition-related initiatives, Q3 2019 adjusted operating margin achieved the lower end of guidance at 26.1%, increasing 50 basis points year over year. While immaterial to earnings, BTG did create an approximate 10-basis-point drag to adjusted operating margin in the quarter.

Now I'll move below the line to interest and other expense. Adjusted interest expense for the quarter was $83 million and now includes BTG, compared to $58 million in Q3 of last year. Our average interest rate was 3.5% in Q3 of 2019, slightly higher than the 3.2% in Q3 of last year. Adjusted other expense was $11 million in the quarter and primarily includes dilution from our equity method investments and transactional foreign exchange losses, including hedging costs.

Our tax rate for the third quarter was negative 38.7% on a GAAP basis and 10.3% on an adjusted basis, below our guidance of approximately 11% for the quarter as we realized the net benefit from stock compensation accounting. Adjusted free cash flow for the quarter was $526 million, compared to $569 million in Q3 of last year. We now expect full-year adjusted free cash flow to be closer to $2.1 billion due to increased working capital requirements, mainly in inventory to support new product launches and overall sales growth. We continue to work to resolve fully the mesh litigation with over 95% of all known claims now settled or in the final stages of settlement, including additional settlements reached during Q3.

Our total legal reserve, of which mesh is included, was $568 million as of September 30, 2019. This is a decrease of roughly $35 million versus June 30th and includes an additional $25 million reserve for international settlements. There's no change to the U.S. outlook, where the known claim count remains flat at 53,000 as does the anticipated amount required for settlement.

Including these international settlements, we now anticipate payments into qualified settlement funds to total $270 million, which will then resolve all significant existing contingencies related to mesh. However, as the legal and administrative processes are taking a bit longer than previously estimated, we now expect payment of this $270 million to extend into 2020 with $120 million paid in 2019 and the remaining $150 million to be paid in 2020. As a reminder, this liability is released from our balance sheet as payments are made out of the qualified settlement funds to plaintiffs. Capital expenditures for the third-quarter 2019 were $121 million.

We expect capital expenditures to be toward the high end of our guidance range of $375 million to $400 million for the year as we build capacity, integrate acquisitions and position the company for continued growth. We ended Q3 with 1.412 billion fully diluted weighted average shares outstanding. I'll now walk through guidance for Q4 and full-year 2019. For the full year, we expect 2019 reported revenue growth to be in the range of approximately 9% to 9.5%.

On an organic basis, we're narrowing our full-year revenue growth guidance to approximately 7.5% and expect the net contribution from acquisitions and divestitures to provide an additional 360 basis points of growth. Of that 360 basis points, we expect a contribution of approximately 155 basis points from BTG interventional medicine and 70 basis points from BTG specialty pharmaceuticals. We expect foreign exchange to be a $175 million to $180 million headwind to revenue for the full year, and we continue to expect FX to be neutral to earnings per share for the year due to our currency hedging program. We now expect our full-year adjusted gross margin as a percentage of sales to be in the range of 72.25% to 72.5% for the full year, narrowing toward the midpoint of prior 72% to 73% guidance.

We will continue to execute on our ongoing standard cost reductions and also expect a positive full-year FX impact to adjusted gross margin of 60 basis points, which remains partially offset by pricing decline. We expect full-year adjusted SG&A to be approximately 35% of sales and down slightly year over year. There's no change to expectations for full-year adjusted R&D spend to be in a range of 10.5% to 11% and full-year royalty rate to remain at less than 1% of sales for 2019. As a result, we expect to achieve 2019 adjusted operating margin in a range of 26% to 26.25%, up 50 to 75 basis points versus 2018.

This revised range reflects the lower half of our original 26% to 26.5% guidance range due to the impact of closing BTG in August. Although BTG contributes operating income, which is largely offset by the incremental interest expense, it is not yet at the company overall rate, so it is dilutive to the total adjusted operating margin by approximately 20 basis points for the year. We remain committed to our improvement goals outlined at Investor Day with a sustainable goal of 50 to 100 basis points of annual operating margin improvement. We expect our full-year 2019 adjusted tax rate to be approximately 9%.

This is based on an operational tax rate of approximately 11%, slightly more than 100 basis points of benefit from the accounting standard for stock compensation and nearly 100 basis points from the discrete tax benefit in Q2, which will not impact our tax rate outlook beyond 2019. We expect below-the-line expenses, which include interest payments, now inclusive of BTG, dilution from our venture capital portfolio and costs associated with our hedging program to be approximately $400 million for the year. Note that yesterday we announced a cash tender offer for up to $1 billion of our outstanding debt securities, subject to financing conditions, and target launching a eurobond offering shortly given attractive rates in European bond markets. We expect a fully diluted weighted average share count of approximately 1.415 billion shares for Q4 2019 and 1.411 billion shares for full-year 2019.

We're raising the low end of our full-year 2019 adjusted earnings per share guidance to $1.55 and maintaining the high end of $1.58. This represents full-year adjusted earnings-per-share growth of 11% to 13%, excluding the 2018 net tax benefit of $0.07 in the base. On a GAAP basis, we expect EPS to be in the range of $0.72 to $0.75. Now turning to Q4 2019.

We expect reported revenue growth to be in a range of approximately 13% to 15%. This represents strong year-over-year organic revenue growth of 8% to 9% with an approximate net 600 to 680 basis points of operational growth contribution from acquisitions and divestitures. Of the 600 to 680, we expect roughly 390 to 430 basis points from BTG interventional medicine and 160 to 200 basis points from BTG specialty pharmaceuticals. We expect the foreign exchange impact on Q4 revenue to be a $20 million to $25 million headwind.

For the fourth quarter, adjusted earnings per share is expected to be in a range of $0.42 to $0.45 per share, representing 10% to 18% growth, excluding the Q4 2018 net tax benefit of $0.01 in the base. And we do not expect any adjusted EPS impact from foreign exchange. GAAP earnings per share for the fourth quarter is expected to be in a range of $0.22 to $0.25 per share. Please check our Investor Relations website for Q3 2019 financial and operational highlights, which outlines Q3 results, as well as Q4 and full-year 2019 guidance, including P&L line item guidance.

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

Susan Lisa -- Vice President, Investor Relations

Thanks, Dan. Kevin, let's open up to questions for the next 30 minutes or so. [Operator instructions] Kevin, please go ahead.

Questions & Answers:


[Operator instructions] The first question is from the line of Bob Hopkins, Bank of America. Please go ahead.

Bob Hopkins -- Bank of America Merrill Lynch -- Analyst

Oh, great. Thank you, and good morning. Congrats on a great third quarter. Two quick questions from me.

First, I think we all appreciated the encouraging comments you made on that ischemia trial. I was wondering if you wouldn't mind just quickly walking us through why you see only maybe a $40 million negative case impact if there's no difference between PCI and drug therapy. Just kind of walk through the math there, if you don't mind.

Mike Mahoney -- Chairman and Chief Executive Officer

Thank you, Bob. Good morning.

Bob Hopkins -- Bank of America Merrill Lynch -- Analyst


Mike Mahoney -- Chairman and Chief Executive Officer

So I'll start with a quick summary, and then I'll let Ian walk you through with some more color. First, we'll just start off by saying it's important to recognize that we certainly have a very long history of clinical evidence in this space, and innovation demonstrates, for the right patients, it's clearly an appropriate and can be life-changing therapy. And second, we do think there's a decent amount of confusion regarding this study and its impact. And as I mentioned in the script, really a third point, we think the financial impact could be anywhere from a positive impact to a slightly negative impact of up to potentially $40 million based on a 5% to 10% reduction in our revenue related to treatment of these patients with coronary syndromes.

So Ian, maybe you could just follow on with some color as to why we feel the impact's in that kind of positive to minus $40 million range.

Ian Meredith -- Chief Medical Officer

Thanks, Mike, and thanks, Bob. To elaborate on what Mike just said, as you know, the population of patients in the ischemia trial are stable patients undergoing revascularization and not those patients that received the vast majority PCIs in the U.S. and indeed globally. 80% of patients undergoing PCI in the U.S.

and, similar, outside the U.S. are done in patients with unstable angina or acute coronary syndrome. And of course, that's -- the role of PCI in those settings is not in dispute nor the focus of the current trial. It's important to note though that, in the ischemia trial, not all patients with stable ischemic heart disease were eligible even to be enrolled in the study.

And then there were significant exclusions after enrollment before randomization. Many of the more complex and sick patients, for example, those with low ejection fraction, heart failure, left main coronary disease, end-stage renal disease, concomitant valvular heart disease, dilated cardiomyopathy, previous unstable angina now stable are all ineligible for this trial. So in all, there are 28 major exclusions from the ischemic -- stable ischemic population in this study. So the translatability of this dataset to the 20% who are in the stable ischemic population probably accounts for significantly less, and so it is on that basis that we think that the impact will be significantly less.

Bob Hopkins -- Bank of America Merrill Lynch -- Analyst

OK. Appreciate you framing that. Just one other quick follow-up. Mike, over the last couple months, there's been sort of three things that have caused a little concern about the 2020 outlook: the BTG growth, the neo data from TCT, and ischemia.

And you kind of addressed all of them in your prepared remarks, but I just want to make sure I heard the message right. Is the message on BTG that you're comfortable with high single digits going forward? And I just want to make sure on neo that you -- despite the data, you still expect that product to grow going forward.

Mike Mahoney -- Chairman and Chief Executive Officer

Yes. We think The Street worries about these things more than we do because we feel like we can manage all of this very effectively. As Ian -- we laid out on the DES piece, this is still an important business for us, but now it's approaching 7% of our mix. Urology alone will be three times bigger than DES given the strong diversification of our -- in the U.S., I should say.

So we think that one has clearly been, we think, overblown in terms of some of the write-ups that we received. On the SCOPE1, the reports I gave in the written script, we do expect there's a likelihood that that growth will slow down on a percent basis in 2020, but we're quite confident that will grow above the BSX corporate average, as well as the IC corporate average really based on the followership that we have in Europe with that valve. Current users are very pleased with the performance of that valve. They continue to use it.

They continue to increase the utilization. And so we'll be anxious to get the second-generation valve approved hopefully mid-2020 in Europe. So we feel good about that. We feel very confident in the full-year guidance that we provided.

The company has a very broad range of diversified portfolio. We continue to advance ourselves in higher-growth markets, and we have very durable high-growth outlook.


And the next question is from the line of David Lewis, Morgan Stanley. Please go ahead.

David Lewis -- Morgan Stanley -- Analyst

Great. Thanks so much. Just a couple quick questions here. Dan, I just want to start with you.

Guidance into the fourth quarter after a very strong third quarter reflects some deceleration, but there's some onetime or some comparability issues from the third to fourth. Can you just help us quantify some of the comparability dynamics from the third to the fourth quarter and how you see or how investors should see underlying business momentum into the fourth quarter?

Dan Brennan -- Executive Vice President and Chief Financial Officer

Sure, David. Yeah. As we look at the sequential going from Q3 to Q4, true, the comp gets a little bit easier as you go from Q3 to Q4. We do have a little bit less of a benefit of days.

We talked about we had a benefit of days in the second half versus the first half, saw more of that benefit in Q3 than we will in Q4. So as we look at the 8% to 9%, I think that's very solid guidance for the fourth quarter. It gets us 7.5% for the full year, and that would be, as Mike alluded to, acceleration again this year versus last year and feel that's a good place to be for the fourth quarter. We obviously have some good launches as well.

We have some momentum with Lotus. We have Watchman going in Japan. We have endo, which is kind of -- had been single digits in the first half, back into the double digits. Urology is going strong, a little bit of a wait and see on Spinal Cord Stimulation.

We did see a bit of stabilization in the quarter, but obviously not to the levels that we've seen in the past. So given the headwinds and tailwinds we have, we think 8% to 9% is strong guidance for the fourth quarter that gets us to that 7.5% for the full year, which is acceleration versus last year.

David Lewis -- Morgan Stanley -- Analyst

OK. And just want to come back to BTG for a second. I think this was one of the issues. With the delayed integration, that business has slowed a bit.

Actually, in the third quarter, the number came in much better than we were expecting. So has there been sort of stabilization and recovery in BTG in the early days of integration? And at recent events, Jeff has sort of talked about the ability of taking that business to sort of 50-50 global mix over the next several years. Just maybe, Mike, your -- recent trends in BTG and so Jeff's confidence in giving that 50-50 global mix imply some pretty dramatic growth dynamics for BTG over the next two to three years. So your confidence in that kind of global mix is achievable here in the near term or intermediate term.

Thanks so much.

Mike Mahoney -- Chairman and Chief Executive Officer

Sure. And sorry, I missed that earlier, Bob, your BTG comment. So just on BTG overall, very excited to finally get this closed. It did take three to four months longer than we planned.

We did have some commercial turnover during that period, which the team, now that it's closed, is shoring that up and really beefing up the resources on the commercial side and, as I said, focused on product registrations globally to enhance that international mix for sure in Europe and in Asia Pac. And importantly, we feel very confident with the cost synergies that we've committed to. And based on really just early feedback from physicians, the combined portfolio in interventional is really kind of what we laid out. It makes sense for interventional radiologists in the interventional oncology space to have these therapeutic capabilities that we have now with cryo and Y-90, as well as the additional capabilities that we have with EKOS and Varithena, and so forth.

So the portfolio fix is really kind of a dream for the commercial team. And based on that, we do feel comfortable that BTG will grow faster than the BSC composite in 2020 and beyond and be nicely accretive to the PI business. We're comfortable with the double-digit growth scenario in 2020 and going forward with BTG interventional. So really, all systems go there.

The team is focused on integration, and we're pleased that we closed the deal.


Next question is from the line of Rick Wise, Stifel. Please go ahead.

Rick Wise -- Stifel Financial Corp. -- Analyst

Good morning. Let me turn to Lotus for a moment. It sounds like everything with the launch is on track. Can you just expand on your comments on the 15 French sheath launch? It sounds like you're still in limited launch.

We've heard from physicians that the smaller sheath size really makes a big difference. You said it was going to be the fourth quarter for a full launch, I think. Where are you -- where in the fourth quarter is it happening? And with that launch, would we expect to see a step-up or an acceleration in Lotus utilization into 2020?

Ian Meredith -- Chief Medical Officer

Thanks very much. Rick, it's Ian here. Yes, the 15 French iSleeve will actually expand the option in terms of how many patients can be treated. Because we're always seeing patients excluded from either our clinical trials or commercial use because their vessels -- peripheral vessels aren't large enough for the existing but very functional delivery sheath.

So the limited market release is going very well. It's on track, and the plans haven't changed thus far. We see this will have an impact on the ability to take in more patients. There'll be fewer exclusions.

Probably 5% of patients are being excluded on vessel size. But the rollout of Lotus Edge, of course, is a planned, controlled release. In the short term, it'll be determined by training.

Rick Wise -- Stifel Financial Corp. -- Analyst

OK. And if I could draw just sort of a big picture and looking at 2020 question. Mike, you've addressed obviously some of the key concerns on Acurate, ischemia, and BTG, but I think there's been a larger discussion and debate about potential 2020 growth headwinds from some of those issues and elsewhere. I know you're not ready to provide 2020 guidance today, but maybe could you help us think, from a high level, some of the puts and takes and maybe what we're under-thinking on the positive side about -- as you look at 2020? And you've sort of emphasized that you think that some of the negatives we're concerned about might be a little less challenging than feared.

Mike Mahoney -- Chairman and Chief Executive Officer

Sure. Thanks, Rick. Clearly not going to give 2020 guidance at this point. I just think there's a lot of very positive things going on in the company.

You look at the momentum that we have really across each business, with the exception of EP, each business, we believe, grew nicely above market. And we had very strong momentum across each region: emerging markets growing nearly 20%; very strong above-market growth in Europe, which is impressive given that most of our products get approved in Europe prior to getting in the U.S.; and very strong growth in the U.S. And importantly, since you said high level, each quarter, we continue to shift our mix of businesses into faster-growth markets as we've outlined numerous times in various calls. So each quarter, that profile in terms of our growth potential gets stronger, and the team continues to grow above market while investing for long term.

And we have many exciting product launches in 2020 with the Exalt scope, which we think will be a really unique platform for us for many years. Across our structural heart portfolio, where the Watchman FLX will be approved; ideally, the Acurate neo2 in second half. Very strong product cadence. You see the -- for example, Neuromodulation.

That business really was solely based on U.S. SCS. And now that business is very diversified, diversified with growth in Europe. And you're seeing tremendous growth out of our DBS platform, which nearly doubled in sales, and we'll have that for a full year in 2020.

So we have many different, I would say, tailwinds to offset some of these, I would say, overblown headwinds, which were ischemia, the Acurate SCOPE1, as well as the BTG. We're very confident in Acurate for the long term. We're very confident with BTG. And our DES business, although not a key growth driver, that's an important contributor.

So I think, overall, we're excited about the future. I think if you look at our Investor Day deck, what we talked about is acceleration. So despite some of these headwinds in '19, we expect to grow organically faster than we did in '18, and that would clearly be our goal for 2020. And at our Investor Day, we talked about acceleration -- organic acceleration in '20, '21 and '22 versus the previous three years.

So we think we have all the tools to do it, and we have a lot of confidence in our team to deliver.


Next question is from the line of Vijay Kumar, Evercore. Please go ahead.

Vijay Kumar -- Evercore ISI -- Analyst

Thanks, guys. Congrats on a really nice sprint here. Mike, maybe turning to some of the positives. The one which really stood out for us was Interventional Cardiology.

I know you mentioned complex PCI, but that doesn't seem to have changed trends. I mean it's been up teens -- mid-teens, pretty consistent. So it really looks like structural heart really changed trajectory here. So I'm just trying to understand how much of this is maybe possibly acceleration in underlying TAVR market growth versus stand-alone Boston outperformance.

I think you mentioned Watchman coming in well above, so maybe tease out what is Boston-specific versus maybe underlying markets trend.

Mike Mahoney -- Chairman and Chief Executive Officer

Yes. So in cardio, the value of complex coronary is probably understated across the company. It may be our most important platform in Asia Pac. Our complex coronary business is growing much faster than BSC composite.

We continue to invest quite a bit in new portfolio there. And that business is really quite a bit larger than our DES business. And so again, that was a purpose strategy from Kevin Ballinger, Lance Bates and the team over the years. So I think complex coronary will continue to be very bright as it gets significantly larger than DES, and also, it positions us more uniquely in the cath lab clinically with doctors.

In structural heart, I think -- well, we know Watchman is doing extremely well. Watchman continues to accelerate growth, continues to deliver strong outcomes and improve utilization. And we're very excited about the FLX progress that we're seeing in Europe and our ability to take share in that market with that second-gen product and that coming to the U.S. So I think we're excited about Watchman as we head into fourth quarter and 2020.

And then our TAVI plans are really on track. We're very excited where we are with Lotus. I don't think -- we haven't seen a tremendous change in terms of market growth, but the outcomes with Lotus have been very favorable. We think it offers some very compelling differentiation versus our competition, and we're really on track with our opening the 150 accounts really per our plan.

And I made comments on Acurate before. So I think the combination of all these things within cardiology are going to lead to nicely above growth versus the BSX overall average as you look forward to 2020. And shortly, that strategy of diversification into complex coronary and structural heart that's working.

Vijay Kumar -- Evercore ISI -- Analyst

That's helpful, Mike. And Dan, maybe one quick one for you. I think I heard you mention BTG about 20 basis points dilutive to margins. That would imply 40 to 50 basis points of dilution in 2020 and possibly some of that being offset by synergies.

Is that the right math just to think about margins for next year?

Dan Brennan -- Executive Vice President and Chief Financial Officer

Yes. I think as you look at 2020, we'll obviously give you a lot more color as we give guidance here at our next call. But obviously, the $175 million in overall synergies, as Mike said, we're committed to that over that three-year time frame. And the BTG operating margin will continue to improve where it'll be -- the Interventional Medicine piece will be approaching PI and then eclipsing PI and eclipsing the overall for Boston Scientific so start to be accretive to Boston Scientific overall.

And we'll give you more on timing on that when we talk about 2020 specifics.

Mike Mahoney -- Chairman and Chief Executive Officer

And maybe to go back -- to follow up on David's question on BTG OUS. I think given the strength that we have in the U.S. and the concentration in the U.S., it's going to be difficult in the near term to get to 50-50 split between international markets and the U.S. given the base that we have in the U.S.

and our expectations for double-digit growth. But that being the case, Jeff and the team are spending quite a bit of resources and leveraging our capabilities in both Europe and Asia, particularly in the regulatory capability area to get these new products approved in Europe into our sales force that's ready to take them, as well as Asia. And also, we're making investments -- more strategic, long-term investments specifically in China with our Y-90 and TheraSphere portfolio to ideally build the capability there, where liver cancer is really two times the size of the U.S. So it may take some time for us to -- in terms of our revenue mix where it's more meaningful, but we're putting the efforts there.

We already have commercial teams in place and a big focus area to grow OUS or international BTG.


Next question is from Robbie Marcus, JP Morgan. Please go ahead.

Robbie Marcus -- J.P. Morgan -- Analyst

Thanks, and congrats on a good quarter. One of the areas you continue to do well in despite some of the underlying market fundamentals is neuromodulation. I was hoping you could break down some of the growth trends of your different business, DBS versus spinal cord stim. And any commentary you can add to the market health overall.

Mike Mahoney -- Chairman and Chief Executive Officer

Sure. So we're pleased with the overall performance of neuromodulation in the quarter. As I mentioned in the script, really the highlight there for that was our deep brain stimulation platform, Vercise, which is doing extremely well globally, taking quite a bit of share and really doubling sales year over year. And we're excited for '20 when we'll have the full-body MRI capability and the directional lead for the full year in 2020.

So we have a lot of optimism in neuromodulation. I think the second highlight there would be our business in the pain overall. So we essentially have diversified our capabilities there in both SCS, Vertiflex, as well as RF. And our Vertiflex acquisition is really exceeding our deal model, and we're really the best company to provide that continuum of care for RF, lumbar stenosis with Vertiflex or SCS.

So I think that positions us more uniquely versus our peers in terms of that full portfolio to address that. We've seen great results out of Vertiflex, great results out of RF. On SCS, the results, we believe, have improved. So it's a positive trend but clearly not to the market levels that we've enjoyed in the past.

We do believe still that, going forward, this will be a mid to high single-digit growth market based on historical trends. And we'll have some easier comps next year in SCS, so I guess that's good to look forward to. But we do have some new software enhancements that we'll be launching in fourth quarter to our platform, as well as the NANS data that I commented on. So I think, overall, the marketplace still is clearly not to the levels that it was in 2018 and historical, potentially low negative single digits, but we believe we continue to grow above market in SCS.

And we're really buoyed and enhanced by the depth of the portfolio with Vertiflex, RF and our DBS platform, which is really kind of in line with our category of leadership strategy. And as we go forward in 2020, we aim to see slightly better overall SCS market trends, which should help.

Dan Brennan -- Executive Vice President and Chief Financial Officer

And then, Robbie, just last point on that. With all of those things in place, and obviously, SCS is not where we had expected it to be or where many had expected it to be, the overall neuromod franchise grew 8% in the quarter. So I think that just really speaks to the diversification within that entire business that it's not just on SCS portfolio that it was able to grow 8% in the quarter.

Robbie Marcus -- J.P. Morgan -- Analyst

And then a quick follow-up here. Complex PCI, over $1 billion business, growing mid-teens, I'd just looked back. For over two years now in double digits, except for one quarter, PCI guidance of low 20s, I think, you said in the script. What's driving such strong growth? And how durable can this be?

Mike Mahoney -- Chairman and Chief Executive Officer

Ian, go ahead.

Ian Meredith -- Chief Medical Officer

Sorry, Mike. So just to speak to what potentially would be driving this. First of all, we have an aging population with an increasing burden of risk factors, and so there is a greater proportion of patients who are elderly who are being treated by percutaneous intervention for the obvious benefits of being minimally invasive. And as you get older, you have more calcification and more disease, and there is a greater focus now on careful and selecting -- selection of lesions to make sure you're treating the right lesion and optimizing the treatment.

So the practice of interventional cardiology is really more sophisticated, and there's an expectation of better outcomes. And you do that by PCI guidance and by functional assessment of the lesions at the time. And of course, changing demographics means we're dealing with a significant burden of elderly degenerative disease. That is the reason it continues to grow.


Next question is from the line of Matthew Taylor, UBS. Go ahead.

Matthew Taylor -- UBS -- Analyst

Thanks for taking the question. I just wanted to follow up on some of your comments on Exalt-D. You seem very excited about it. You mentioned the FDA decree earlier this year.

Can we talk about what that could mean, and also any expectations that you have for the upcoming panel in November on duodenoscopes?

Mike Mahoney -- Chairman and Chief Executive Officer

Yeah. So really, in terms of our Exalt platform and the future products that fall behind it, really on track. And no new commentary, other than we expect -- we're still on track for year-end 2019 approval, which we -- and we've also initiated a post-market clinical trial, which will start in first-quarter 2020. But we expect to see our first revenue with Exalt near the end of the year here, and we think it'll be a significant growth driver for us in 2020.

We think the trends and that FDA advisory certainly are a tailwind for Exalt. We -- and kudos to our team for really identifying this opportunity nearly three to four years ago. So we think the timing and the physician excitement -- and maybe the FDA supported this, all nice tailwinds for this platform, and we think we uniquely delivered -- uniquely capable of delivering this based on our results and expertise that we've created with both LithoVue in urology and digital SpyGlass in endo. So we have the manufacturing and the ops and the supply chain and the R&D capability to deliver this one, as well as the future scopes with it.

So it's one of our more exciting launches in 2020.

Matthew Taylor -- UBS -- Analyst

Thanks. Just a quick follow-up on Ian's comment before on ischemia. I was just curious if you could expound on what you think drives the positive results. What do you think can come out of the trial that can actually drive more stenting? Or how do you see that as a positive? What's the probability of that?

Ian Meredith -- Chief Medical Officer

Well, I don't think it would drive more stenting unless we change guidelines. If we chose to use the word positive to say could the trial actually have a positive result, in other words revascularization by either bypass graft surgery or percutaneous intervention, be better than just optimized medical therapy. And the reason for considering that as a possibility is that, unlike previous trials, there was a dedicated effort here to determine that the patients who were enrolled in the study did, in fact, actually have objective evidence of ischemia. And as you know, 85 -- 80% to 85% of the patients in this study in both arms have moderate to severe objective evidence of ischemia, not symptoms but ischemia on functional testing.

Now by doing that, you know that you have the greatest likelihood of showing the benefit of revascularization. And many previous registries and small studies have suggested the greater burden of ischemia you have, the more likely that revascularization is a better option than optimized medical therapy. And that -- this is the first trial to actually test that out. And despite all of the potential vagaries around the trial, if that plays out, it is -- there is a possibility that it could be a positive result because we're treating the right patients in this subset to actually test that question.

So that's why I would think that there is a reason to -- not so much doom and gloom because the burden of ischemia might favor an outcome that is positive. I'd make another comment on the quality of life. Everybody thinks that it's going to be positive on quality of life. Just remember that the Seattle questionnaire score was 80 out of 100, 100 being perfect and zero being terrible.

So the patients were already at very minimal symptoms. 80% of the patients had monthly or less frequent angina. So it is going to be hard to show the improved quality of life in patients who are having symptoms only a few times a year.


Next question, Larry Biegelsen, Wells Fargo. Please go ahead.

Larry Biegelsen -- Wells Fargo Securities -- Analyst

Hey, guys. I don't know. I thought I heard a joke in the background there, Mike, about asking me a question. But thanks for taking my question and congrats on a nice quarter.

I guess I will ask one ischemia question, Ian, and then just one follow-up on emerging markets and China. Ian, I'm just curious if you have thoughts on U.S. versus OUS implications for this study, if you think they'll be different. And second, what is your -- listening to your response on the last question, Ian, what's your -- what's the base case here? It sounds like you think it's going to be hard to show quality of life benefit, but it sounds like you think there might be a hard outcome death, MI, hospitalization for angina, etc., benefit based on what you said on the 80% to 85% of patients having moderate to severe ischemia.

And I just had one follow-up.

Ian Meredith -- Chief Medical Officer

OK. Well, first, to deal with the OUS versus U.S., as you know, Larry, there's been a significant shift toward a great proportion of PCIs being undertaken in unstable angina and acute coronary syndrome. That trend has been a global trend for over 10 years ever since the Courage trial in 2007, and we've done considerable research over the last few weeks to see whether that factor is sustained. Just to look in the U.S., we know that the NCDR Cath-PCI Registry has shown that trend away from stable angina.

And similarly, there is data from the Sweetheart Registry, the China Peace registry and other international registries that all point to the same trend. Maybe a percentage point here or there, but overall, we think there'll be a consistent pattern in the response to this trial, positive or negative, U.S. to OUS because, overall, the proportion of PCIs undertaken for unstable acute coronary syndromes outside the U.S. is essentially the same as inside the U.S.

And there is very good data actually from the -- published this year from single centers, both inside and outside the U.S., showing the same sort of trends over the last 10 to 12-year period. That was the first question. The second question you asked was -- I've forgotten.

Larry Biegelsen -- Wells Fargo Securities -- Analyst

Just what's your base-case assumption kind of on the outcome of the trial?

Mike Mahoney -- Chairman and Chief Executive Officer

I really feel like the ischemia level of questions are so disproportionate to the overall business. The Megatron launch in the U.S. will likely have a larger impact than the potential downside scenario that we're talking about with the ischemia trial. It's really...

Larry Biegelsen -- Wells Fargo Securities -- Analyst

All right. Fair enough. Just for my second question, just on emerging markets. You had a nice quarter there.

There's been little concern about slowing growth in China. So I guess my question is kind of what are you seeing there, Mike? And any update on the drug-eluting stent price cuts in China? Any more visibility on timing or magnitude?

Mike Mahoney -- Chairman and Chief Executive Officer

Sure. Thanks for the non-ischemia question. The emerging markets grew almost 20%, so it continues to do extremely well. It's really a combination of our consistent -- it's really the same playbook.

We've seen great growth in Latin America, great growth in China and really nice growth in the ASEAN countries, as well as some parts of Europe, but it's really a combination of a couple things. It's the diversification of the portfolio. Whereas, eight years ago, it was drug-eluting stents, and now you're seeing complex coronary being larger than DES in those markets with those tailwinds that we talked about. Ian mentioned the patient population, but as importantly, the portfolio investments that we've made have driven complex coronary to be very important businesses there.

And then you see the diversification of endo, amazing growth with PI, particularly in Asia, great growth on our interventional oncology business. And you're starting to see the impact of really just the diversification of BSC other than drug-eluting stents. You're seeing very strong growth with Watchman in China. We're excited to bring our structural heart TAVI portfolio to many parts of Asia Pac.

So it's the diversification of the business, the focus that our global presidents put on it, the allocation of resources and really the smart prioritization of which products and which countries make the most sense to invest in and kind of the speed of the team to execute on the plan. So we're confident in the emerging markets growth. I think in terms of the China DES tender that you'll see, again, there could be some upsides or downsides there based on how these tenders go. But I think, overall, we have a very strong balanced portfolio in China that continues to grow very well beyond DES.

So we hope to win these tenders, but we have a very strong diversified business there.

Susan Lisa -- Vice President, Investor Relations

Great. Thanks, Mike. With that, we'd like to conclude the call. Thanks for joining us today.

Appreciate your interest. Before you disconnect, Kevin will give you all the pertinent details for the replay.


Thank you. Ladies and gentlemen, this conference will be available for replay starting today at 10:30 a.m. Eastern time and will run through November 6 midnight. You may dial the AT&T Executive playback service by dialing 1 (800) 475-6701 with the access code 472683.

International callers may dial (320) 365-3844, access code 472683.[Operator signoff]

Duration: 60 minutes

Call participants:

Susan Lisa -- Vice President, Investor Relations

Mike Mahoney -- Chairman and Chief Executive Officer

Dan Brennan -- Executive Vice President and Chief Financial Officer

Bob Hopkins -- Bank of America Merrill Lynch -- Analyst

Ian Meredith -- Chief Medical Officer

David Lewis -- Morgan Stanley -- Analyst

Rick Wise -- Stifel Financial Corp. -- Analyst

Vijay Kumar -- Evercore ISI -- Analyst

Robbie Marcus -- J.P. Morgan -- Analyst

Matthew Taylor -- UBS -- Analyst

Larry Biegelsen -- Wells Fargo Securities -- Analyst

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