EXCLUSIVE: The next big areas for Intuitive

Intuitive - the next big areas

Okay folks - if someone grabs my attention at JPM then I’m going to get to work. Like everyone else I’m guessing where Intuitive is going next. Below I'm going to give you my insights into where I think the next big thing is coming from a very small thing.

At JPM Gary Guthart mentioned 3 areas where he (they) are dissatisfied with outcomes.

Lung - Endometriosis - Mitral Valve - and he said “Don’t read things into that.” Sorry Gary - you say that… I’m going to dig in.

Here’s what I found out…. and it is all 100% wild specualtion....

Possible next big areas

I am not going to go into  a lot of details about how I conclude this but it takes me a while. 35 years of doing this has given me some abilities to read the tea leaves. Plus I look from 30,000 feet - and I see the pieces across Industry. For me these things just jump out as super obvious - BUT I’m often wrong so don’t count on this.

Here are my thoughts in no order of areas I think we will see soon:

1. We are going endolumenal (hold on)

2. We are going endovascular

3. We are going ablation

4. We are going Mitral

5. We are going intravascular

6. We are going CHF (congestive heart failure)

7. We are going metabolic disorders

8. We are going endometriosis

Several things are coming together where I see that Intuitive is about to branch into MIS therapies that people will maybe not quite understand. I see many companies out there moving into massive spaces - and bringing diagnosis and therapies in ways that people did not think of just a few years ago.

I see some big moves - with JNJ having bought Hansen (okay Auris) and now Abiomed and Shockwave: and that sets the scene for the future battlegrounds.

I see ION, and I have waxed on about how that system will be ported across to endolumenal GI and I am 100% confident that ION will follow Monarch into urology with PCNL. It’s just so logical.

But I also see the evolution of ION also into intravascular - and cardiac - and this one image may seem insignificant to many - but to me it is small yet massive. In 10 years many will understand what this enables.

Intuitive Hood

You see one of the issues with working inside the heart - or blood vessels - is that you have blood in the way. So to image the pathology you normally need external imaging like MRI, Xray, Ultrasound or intravascular imaging like IVUS. You can’t see though blood — right?

Stop - hang on wait. WTF is Steve talking about this stuff - he’s a robot guy. Quick background - I am a physiologist by background and training. And I spent a huge part of my mid career in cardiovascular.

I created the brand CardioVations at JNJ and was part of the team that acquired in Heartport - remember those guys? No - get googling. I then built some stent companies and even have a few patents around cardiovascular products. I was part of ORQIS in congestive heart failure and I was involved in looking at some ablation therapies in CV.

I was also part of the team looking at minimally invasive valve repair and replacement - and beating heart and off pump. I’ve worked on septal devices (Amplatzer style) for ASD and more. So I combine that with my robotics knowledge - my vast endolumenal knowledge (MINOS medical was mine) - and bingo this all now falls into place in my mind.

I think Intuitive is going in on Endovascular - Cardiac First

The heart is unfinished  business for Intuitive - they started there and they are going back there. It is a vast market - still underserved and robotics is flooding there (SSi for one). Capstan medical - if you didn’t see the move by an ex-Intuitive engineer Greg Dachs - your are not reading the tea leaves. They are looking at endocardial robotic valvular replacement.

Intuitive in robotic cardiac

That little cone I showed you above is tiny - it can actually go inside the heart. It enables things like trans septal - or even coronary imaging. Think of it creating a small isolated operating chamber. I will not go into now but book some of my time if you want to know also about motion stabilisation methods using small hoods and more.

I have a weird knack of reading patents and putting all the pieces together in my head and coming up with scenarios. This is a big big small thing. It is the key to intravascular real time visible imaging. It is key to intra cardiac imaging - and a few more things I will not go into now.

Now with ION you overcome one of the things that we (when we took Heartport) struggled with. Manipulating catheters into places like the coronary sinus and then “keeping them there” was a challenge. Getting right to the annulus of say the mitral valve was a challenge. And staying there. Why? Because the heart is beating and always in motion - and it is full of fluid. It’s a tough environment to put things in place wit precision and keep them still. But robots are very good at that - especially if you synch them with the heart.

I see - the “mitral valve” don’t read anything into it - by Gary - and it got me curious.

But I was always curious - if they go intravascular what’s the big thing they bring - well visualisation will be one thing. And they have found a smart way to do this. But it’s clever beyond that - and I’m not going to go into all the details today but the “Endo Hood” not only allows the intra cardiac intravascular visual imaging - it allows the deployment of fluids - (including thermal fluids) - and ablation arrays. As well as transparent fluids…. Ya dig.

Intuitive goes all in on ablation

Catheter and guidance systems like Biosense have been around for decades. And once you can get a catheter to the heart you can start to ablate - but ensuring the ablation arrays are in good contact with the tissue and getting tissue effect are not always that easy. If you end up with partial ablation patterns then you might not get the effect you want.

But if you can deploy the array and watch visually in real time (white light) - and then have even a feedback method - you might be able to apply ablation for things such as atrial fibrillation in a more effective way.  (You come after our turf we come after your turf.)

However, I think we have to start to think further along than this and start to think of delivering energy for other cardiac impacts and conditions. I’ll come to the mitral valve in a minute.

To deliver energy for ablation you need to create an ablation system and competency - and well Intuitive over the years have been building up their advanced energy knowledge and I think now they are looking at ablation delivery by electrical, PFA (Pulse field ablation) and the possibility of maybe also using thermal fluids. (Talk about sonic energy later for Lithotripsy)

I think the first two are the most likely out of the gate.

So this means - I think - they are about to up their game in ablation delivery - and that takes us into Mitral valve, and ablation for congestive heart failure. All of course delivered by their visual system on the end of a modified ION that can robot navigate to the areas inside the heart.

There’s also absolutely no stopping it to be used as a well as a Shockwave competitor - for IVL - into vascular lithotripsy - and I am convinced they will also go there for the major peripherals and I think they have something special in mind for coronaries. You don’t need to have the ability to access the coronary sinus / operating visually if you don’t plan to deliver something. And stents ain’t the future for Intuitive.

But let me leave the heart for a minute and head to other areas. If you haven’t heard of Endogenix - then you need to go do some Googling there.

Many metabolic and disease states can be potentially reversed or paused by the application of pulsed field ablation (PFA) to the endo GI tract. Often at the area of the pancreas ampulla of vater but also in the duodenum and stomach. And other areas we are discovering. Go do some work on this PFA of the mural structures if you have some time as I won’t do that lesson today.

There is an exploding field in the use of energy to affect cellular metabolic changes through this mechanism - and Intuitive are right there. You just use their upcoming (my guess) GI based ION and you can now also deliver PFA there. Especially if you are developing that entire capability.

Intuitive patent on metabolic treatments

So this competency of ablation is going to be applicable in all the areas they have highlighted at JP Morgan this week. But in way way way more areas beyond that. And the robotic delivery of this ablation is the breakthrough that’s needed. Precision and stability to deliver target ablation under real time visualisation. I think ION is about to explode !!!!

The Mitral Valve

The mitral valve is nothing new for Intuitive - they were back there in the late 90s. But as Gary pointed out, mortality after a procedure is crazy high. So how about if after a DV5 (the force feedback could be a nice addition to do valvular repair) you could go in with ION CV (that’s what I’m calling it for now) and do a tune up procedure of that valve and surrounding structures. Under full visualisation in real time - while the heart is working - endo cardiac - BOOM!

Or do a stand alone Mitral valve repair - ether with a physical clip system - or an ablation annulus tightening? The “hood” could deliver both ablation arrays - point ablation or even clip systems that could be used to tighten the mitral valve in a very minimally invasive way.

Now this could be used as a stand alone - or post surgical repair (well noted in the literature.) But the ability to drive there robotically and then see the repair in real time with visual imaging would be an utter game changer. Not interpretting just US imaging etc.

And hey - often MV repair and atrial ablation are done together - so with one system you could easily do concomitant MV repair and atrial ablation - single treatment which would be game changing. But an ION CV system would allow this - and the “Hood” would be the enabler.

As a side note and not for today - but the "hood" (can I TM that?) also allows a trans septal approach and then post system transseptal closure. If you apply the hood to the atrial wall and apply clips you can close any septal defect (congenital) or that you make to gain access to the MV. This allows venous access to the cardiac anatomy as opposed to a trans femoral approach. Plus is allows access (venous) to the tricuspid valve for other valve work.

I’m not reading anything into anything Gary… but I am.

What about Intravascular (bigger speculation)

JNJ buying Shockwave was big big news. And it shows the value of that rather massive market. And well if you have ION intravascular systems that can deliver acoustic energy you have a very precise and controlled way to deliver peripheral IVL but… how about if we can miniaturise that all down and get that to be accessed through a coronary opening. This allows either stentless procedures or assistance in improving stent delivery. (Coronary IVL well known)But if they go there - with a robot - you’ve just leapfrogged the $13B acquisition by JNJ.

It’s done today using PCI - but how about if this could be done using an ION and full visualisation? Could we get better results? I’m speculating more than I normally would.

ION for Intracoronary ?

(You have no idea what’s in my brain about what I think is coming did the pipe in crazy land.)

I’m going out on a limb here but I think the hood - maybe even in conjunction with a retrograde perfusion  system (I worked a lot with Heartport) via the coronary sinus - and an ION CV delivered “shockwave” like therapy could be part of this broader intravascular roadmap. The robot makes this “easy.”

The combination of the already used pre planning navigation - ION robotics and energy… well I think this is coming in the next years.

Metabolic disorders

I’m all over the place here so sorry - but I wanted to dig deeper into the metabolic disorders as I think it is on the roadmap and once we get the ablation systems up and running and a GI catheter for ION (ION GI) - then I think this could be a massive breakthrough.

To say again - the delivery with precision and stability of arrays into the GI tract can be to deliver treatments for diabetes Type II, Obesity, and more broad - sleep apnea or even polycystic ovarian disease. (Slight tangent) and other metabolic disorders such as Chrone’s IBD and more. All areas where Intuitive have peripheral interests today (maybe not diabetes). But I’m going to go out on a limb here and say that as a spin off from the work in cardiac ablation - there will be a broader application to metabolic diseases by GI applications. The ION robot is the key platform and the imaging combined with route planning - stability and precision will be the game changer for all these application. GI endoscopy companies - sharpen your pencils.

Sorry I digress.

Endometriosis intrigued me

Already today da Vinci is used in major resection surgery for endometriosis. It’s in the hands of a very few hyper skilled surgeons. But again (just because I’m so odd) I worked at Gynecare for many years and looked at Endometrial ablation. There’s that word again. (Is there any field I’ve not worked in? Shit I’m old.)

You see the endometrium is very sensitive to ablation technology - thermal, electrical or cryogenic. There have been lots of systems out there to deliver intrauterine ablation. I was in charge of Thermachoice for quite a while in there EU.

This is a massive area with gradations of disease that Intuitive could absolutely impact. If you have an ablation system you could of course do intrauterine ablation. But you could also do diagnosis - and I’m seeing ION again.

I wondered if you could drive an ION into the uterus - and take a sample of the uterine wall as a biopsy. BUT now go deeper and drive up through the fallopian tube - out of the fimbria and you are now in the abdominal cavity (sterility is another issue here but I’m in fantasy land so stick with me) and then you can control the robot in the abdomen and do either visual diagnosis using ICG style markers or biopsy around the pelvis?

Yeah maybe easier to apply a diagnostic and endometriosis ablation laparoscopy side. So you could use any upcoming near infrared system on the DV5 - to highlight the endometriosis (technique is well known) and then apply an ablation technology (you now have ablation) to ablate the endometriosis abdominal side? Am I stretching too far? And this could reduce the amount of surgical resection needed.

All I can say is that this is a massive underserved market - and well Storz have this technology in their imaging systems and now have a robot… so maybe - just maybe that is why it was on the JPM slides?

Summary

Sorry if today’s post seems a bit jumbled but it is because their technology stacks - and market appetite are a bit vast here.

I think ION is the central hub. CV and GI are coming as well as PCNL in urology. But I think it’s the ablation angle that is the tech stack where we get to see MIS applications to treat an array of disease states well beyond surgery.

If you think the number of procedures on their roadmap is big for what we know about - you put this in and well - the procedure roadmap is almost too big to understand.

The competition - JnJ and Medtronic have a hold in cardiovascular - and I am convinced that Intuitive - for many reasons of improving health and maybe also for making sure they are in that market - will jump into cardiovascular. Doing a leapfrog and using endolumenal ION as the catalyst I think makes sense. The ablation part of it is not hard and they have that competency in house.

We will see ION add ablation for lung, we will see a lithotriptic technology for urological - and that ablation technology and know how will go to cardiovascular - Intravascular - and metabolic diseases. Look for an almost entire ablation division. Wait…Then they will add competency in sound based technologies of acoustic shock waves for all kinds of lithotriptic technologies.

Okay so they have an entire advanced ENERGY division - with all kinds of advanced and standard energy modalities to be deployed all over the body to give new MIS treatments. Because this is the future. Oh - nnd if you kick the legs out of JNJ or MDT in cardiovascular (shockwave could seem expensive if Intuitive drop into that market with a shockwave beating robot) then you steal fuel from them to come after you in robotics. Smart.Well this is what I would do. Well this is why no body wants me as a strategist in their company hahahahaha - too mad? Too forward thinking?? ;)

Look this is all just 100% speculation and fuel for thought. I have zero inside info - I just have a lot of tea (I’m British) so a lot of tealeaves to sift through. I fortunatley have a very broad view of medtech so come to some odd conclusions that are more often wrong than right. But would love to know your thoughts.