Truist Securities brought together 11 key opinion leader (KOL) physicians to share insights on the latest advancements in ENT/Sleep, Ophthalmology, Electrophysiology, Structural Heart, Robotic Surgery and Upper Extremity Orthopedics. We’ve outlined the most relevant findings from our MedTech KOL physicians in each of the six specialty area panels to highlight how breakthrough developments are progressing.

Richard Newitter Managing Director, Samuel Brodovsky Managing Director

ENT/sleep

GLP-1 agonist drugs are reshaping more than bariatric medicine. Following drug-enabled weight loss, many patients with obstructive sleep apnea (OSA) will achieve a BMI that allows them to fit the eligibility criteria for hypoglossal nerve stimulation (HNS). While weight reduction itself can be curative to OSA, in many cases this is because OSA is correlated to anatomy, not just BMI. High BMI patients with OSA for an extended period can also develop neurological deficits that don't improve with reduced BMI, despite BMI originally causing their OSA. New iterations of current HNS devices should allow faster procedure times and reduce requirements for drug-induced sleep endoscopy. These improvements, along with new devices coming online, provide a significant opportunity to expand HNS volumes.

Ophthalmology

We’re watching closely as iDose enters the glaucoma treatment market. This biocompatible titanium implant elutes drug molecules within the anterior chamber of the eye. The device may see some adoption in standalone implantation procedures, initially with the Medicare fee-for-service plus secondary insurance populations where reimbursement is more assured. Results demonstrating longer-term efficacy could lead clinicians to substitute iDose for other devices in standalone cases.

The opportunity in combination procedures could be great, though here again, providers will be cautious until they’ve confirmed reimbursement levels. 

Cost may limit broad usage at first, but less price-sensitive patients with secondary insurance should spur early adoption. This group represents a significant market for iDose even before routine Medicare reimbursement is assured. Current FDA labeling does not include replacement; that may change over time. Expect to see broader use following a label change. Concerns about potential endothelial cell loss (ECL) may also hamper rapid adoption, but only briefly. While ECL is always top of mind, relatively long-term data from earlier studies appeared reassuring. It will likely take positive 5-year ECL data to definitively resolve those concerns.

Electrophysiology

Pulsed field ablation is poised to replace a substantial percentage of radiofrequency ablation and cryoablation procedures. Compared with earlier methods, pulsed field ablation offers efficiency and safety improvements that will increase operating room capacity as well as referrals. These advantages should encourage widespread adoption among providers and acceptance by insurers. The newer technique should expand the total number of medical ablations, in addition to replacing older methods. If reimbursement materializes for a combined approach, procedures that couple pulsed field ablation for atrial fibrillation with left atrial appendage (LAA) treatment could benefit LAA device manufacturers. 

Structural heart

Transcatheter Aortic Valve Replacement (TAVR) appears relatively stable, with seasonal fluctuations and moderate growth, as undertreated aortic stenosis patients receive appropriate treatment. As providers fulfill this reservoir of need, TAVR volume may remain stable or decrease slightly. In contrast, mitral valve repair volumes are increasing, possibly due to reinvigoration in this segment with the entry of the precision transcatheter valve repair system. Don’t expect significant shifts in market share between manufacturers or changes around small annulus (SA). In fact, manufacturers often overestimate SA in overall demand for TAVR. 

The greatest opportunity in structural heart practice centers on tricuspid valve replacement and repair—perhaps eightfold the patient opportunity of TAVR. There are, however, several limiting factors that may slow the pace of adoption. Certified tricuspid programs are unlikely to be as common as those for TAVR and mitral. Cost may pose a barrier as well, especially given the lack of medical urgency for this type of treatment. The longer-term outlook remains positive for tricuspid repair and replacement alike.

General surgery robotics

The latest iteration of the da Vinci surgical system (D5) may meaningfully impact the general surgery robotics landscape, both now and in the future.

Force sensing features could entice older surgeons, and those new to robotics, to push farther into underpenetrated procedure categories. For more experienced practitioners, force sensing may inspire confidence to tackle especially sensitive surgeries, including Whipples and certain thoracic procedures. While hospital systems aren’t rushing to upgrade all their systems at once, D5’s increased computing power, data processing capabilities, and optimization potential are significant. These advantages future proof D5 to no small degree, and could prove transformational, driving accelerated penetration that could reach into new procedure areas.

GLP-1 drugs’ ripple effects appear in general surgery, lowering demand for robotic bariatric surgery as patients try a pharmaceutical approach to help them fulfill their health goals. The drugs have been on the market for a while now, and the rate of decline in bariatric surgery is stabilizing. At this point, there’s an influx of patients for whom GLP-1s were ineffective, intolerable, or too costly and who may now be more receptive to bariatric surgery than they were in the past.

Upper extremity orthopedics

Robotic surgery is making inroads into shoulder implants—a surgery segment for which volume trends remain robust. Existing experience with hip and knee robotic surgeries should pave the way for more rapid adoption for robotic shoulder surgeries. Generally speaking, from a shoulder implant market share perspective, “robotic haves” (companies with robotic shoulder replacement systems) should be in a better position than “robotic have-nots”. There’s an important caveat: Institutions are likely to stick with the system they have. That means they’ll purchase shoulder components aligned with the robotics system they’ve originally purchased, regardless of (relatively minor) performance, quality, and price differences between shoulder implant robotics systems.

Our MedTech KOL physicians 

Cardio: Electrophysiology

Dr. Seth Goldbarg, MD

Director of Cardiac Electrophysiology, New York Presbyterian, Queens

Dr. Manish Undavia, MD

Cardiac Electrophysiologist, NYU Winthrop Hospital

Clinical Assistant Professor, NYU Long Island School of Medicine

Ophthalmology

Dr. Jonathan Ellant, MD 

Ophthalmologist, Gotham Eye Associates 

Chief of Ophthalmology, Veterans Affairs Medical Center (San Diego)

Clinical Professor of Ophthalmology, UCSD School of Medicine and Shiley Eye Institute 

ENT/Sleep

Dr. Boris Chernobilsky, MD 

Former Director of Sleep Surgery at NYU Langone Health System

Dr. Atul Malhotra, MD 

Vice Chair of Medicine for Research and Tenured Professor and Research Chief of Pulmonary Critical Care Sleep Medicine and Physiology, UCSD 

Orthopedics (Shoulder Robotics Focus)

Dr. Ajay Padaki, MD 

Orthopedic Surgeon, Northwell Health 

Assistant Professor of Orthopedic Surgery, Hofstra University Zucker School of Medicine 

Dr. Robert Brochin, MD 

Orthopedic Surgeon and Assistant Professor of Orthopedic Surgery, Loyola University Medical Center 

Cardio: Structural Heart

Dr. Nino Mihatov, MD 

Assistant Professor of Medicine at Weill Cornell Medical College 

Dr. Keith Allen, MD 

Director of Cardiothoracic-Vascular Surgery Research, Director of Structural Heart Research, and Attending Surgeon at St. Luke’s Hospital 

Robotics Surgery & Future Trends with a Focus on ISRG’s da Vinci 5 System

Dr. Vikrom Dhar, MD 

Bariatric Surgeon at Northwell Health Physician Partners 

Minimally Invasive Surgeon at Lenox Hill Hospital

Truist Securities brings you a new perspective on the MedTech industry.

The Truist Securities medical technology team bring industry insights that can help you grow and compete in an intensely dynamic business. Talk to the Truist Securities team for solutions and support that helps you benefit from what’s coming next.

Purple PaperSM Digital Transformation

Learn how you can put advanced technology to work for your business.