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Livanova (NASDAQ:LIVN)
Q1 2019 Earnings Call
May. 01, 2019, 8:00 a.m. ET

Contents:

  • Prepared Remarks
  • Questions and Answers
  • Call Participants

Prepared Remarks:


Operator

Good day, ladies and gentlemen, and welcome to the LivaNova PLC first-quarter 2019 earnings conference call. [Operator instructions] As a reminder, this conference call is being recorded. I would now like to introduce your host for today's conference, Mr. Matthew Dodds, LivaNova's senior vice president of corporate development.

Please go ahead.

Matthew Dodds -- Senior Vice President of Corporate Development

Thank you, Lisa, and welcome to our conference call and webcast discussing LivaNova's financial results for the first quarter of 2019. Joining me on today's call are Damien McDonald, our chief executive officer; Thad Huston, our chief financial officer; and Melissa Farina, our vice president of investor relations. Before we begin, I would like to remind you that the discussions during this call will include forward-looking statements. Factors that could cause actual results to differ materially are discussed in the company's most recent filings and documents furnished to the SEC, including today's press release that's available on our website.

We do not undertake to update any forward-looking statement. Also, the discussions will include certain non-GAAP financial measures. Reconciliations to the most directly comparable GAAP financial measures can be found in today's press release that's available on our website. We have also posted a presentation to our website that summarizes the points of today's call.

This presentation is complementary to the other call material and should be used as an enhanced communication tool. You can find the presentation and press release in the Investor Relations section of our website under News & Events, Presentations at investor.livanova.com. With that, I will now turn the call over to Damien.

Damien McDonald -- Chief Executive Officer

Thanks, Matt. Welcome to our first-quarter 2019 conference call. Today, we will discuss our first-quarter results, outline our plans to address the sales shortfall in neuromodulation and Perceval in the U.S. and updated guidance.

To be clear, we are disappointed in our first-quarter results. While we have made significant progress in transforming LivaNova portfolio over the last two years, we have more work to do. As Thad and I will explain in more detail during this call, we are implementing several actions to address the root causes of the sales shortfall and leaning in harder on our cost structure to countermeasure the near term impact. I'm going to start off by discussing our sales results by business and provide color on actions already under way.

After my comments, Thad will provide you with additional detail on the financial and our revised 2019 guidance. Then I will wrap up with closing comments before moving on to Q&A. On April 5th, we announced preliminary first-quarter 2019 revenue results. The U.S.

neuromodulation business experienced an unexpected weakness due to a combination of factors, including competitive dynamics and sales force turnover. In addition, toughness in Perceval sales negatively impacted the cardiovascular business during the quarter. All of the weakness we saw occurred in the U.S. as both Europe and rest of world grew above plan.

Turning now to our net sales results for the first quarter, which will all be stated on a constant-currency basis. Total net sales were up 4.2% compared to the first quarter of 2018. Cardiovascular showed strong operational growth in the quarter, while neuromodulation was below expectations. Cardiovascular sales were $155 million, up 5.1% from the first quarter of 2018 due to growth in cardiopulmonary and the inclusion of ACS.

Cardiopulmonary sales were $122 million in the quarter, an increase of 2.6% versus the first quarter of 2018. Heart-lung machines grew double digits driven by strength in both S3 conversions and competitive placements. Our oxygenator sales declined due to the termination of a Canadian distribution agreement that grew overall. In the first quarter of 2018, sales from the Canadian distribution agreement was $7.8 million and were located in the rest of world category of cardiopulmonary.

Excluding this impact, oxygenator sales posted another solid quarter. Turning to heart valves. Sales for heart valves were $26 million in the quarter, a decline of 11.2% versus the first quarter of 2018. Perceval declined in low single digit overall driven by declines in the U.S.

We continue to believe the U.S. issues are related to execution, not the impact of transcatheter valves. ACS reflects our TandemLife business that we acquired in April of 2018. And we're very pleased to see sales in the first quarter in excess of $8 million, representing greater than 40% growth versus the first quarter of 2018.

We believe last year's sales force expansion is now gaining traction with strong growth across all product lines, especially ProtekDuo. Now lets turn to neuromodulation. Sales were $95 million, up 2.3% versus the first quarter of 2018. In the U.S., sales decreased 1.4% driven by competitive pressures and field turnover.

Our subsequent analysis for this shortfall leads us to believe the following: First, we have no evidence that we lost market share to other implantable therapies. Second, we saw a deviation from historical trends in the timing between new patient identification and implant. We believe this was related to the initial enthusiasm by patients to Epidiolex as initial prescriptions written have meaningfully uptake prescriptions filled. Third, we have recently seen a step up in competitive hiring and while our turnover was only slightly higher than normal trends, it had a sizable impact on two U.S.

sales regions in the first quarter. And fourth, competitive dynamics and turnover led to a reduction in customer purchasing patents at the end of the quarter. We now believe we have a better understanding of the situation surrounding our U.S. neuromodulation business, and have formed and implemented dedicated teams to oversee programs designed to address the current market dynamics, including sales force retention and compensation plans, customer and territory optimization, competitive positioning and replicating best practices.

While we are confident in the short term challenges, we are resetting our expectations for 2019, which Thad will run through during the financial update. Turning to SenTiva. U.S. adoption continues to increase and represented 67% of our generated sales in the first quarter.

We saw another strong growth quarter of double-digit sales in Europe based on continued adoption of SenTiva, which was launched last April. EU adoption is now 55% of generated sales with strong uptake in the U.K., Nordics, Germany and Spain. Our rest of world region delivered another great quarter driven by strong performance in the Middle East, China, Brazil and Russia. Finally, a neuromodulation pipeline continues to make good progress in both the treatment-resistant depression, or TRD, and heart failure programs.

In TRD, we are making solid progress on site recruitment and engaged a high profile CRO and still expect their first implant in the third quarter. While we continue to build that TRD team and attract talent with the addition of two senior leaders, including the head of our TRD program globally and a commercial VP. In heart failure, our ANTHEM-HFrEF U.S. pivotal trial continues to enroll faster than our expectations at over 60 active sites.

And we recently presented encouraging long term 30 and 42 months data during the American College of Cardiology Annual Meeting in March. We are confident in our growth prospects and we'll continue to focus on execution, strong portfolio management and developing the talent and culture of LivaNova. I'll now turn the call over to Thad for an overview of our financial results. Thad?

Thad Huston -- Chief Financial Officer

Thank you, Damien. I'm going to discuss the first-quarter financials in greater detail and provide our revised 2019 guidance. As Damien mentioned, sales growth in the first quarter was 4.2% versus the first quarter of 2018 led by growth in HLMs and oxygenators offset by lower growth in neuromodulation. Adjusted gross margin as a percent of net sales in the quarter was 69.3%, up 240 basis points from the first quarter of 2018.

The margin improvement was driven primarily by mix and price. Adjusted R&D expense in the first quarter was $37 million, compared to $29 million in the first quarter of 2018. R&D as a percentage of net sales was 14.7% versus 11.6% in the first quarter of 2018. As we previously discussed, R&D is increasing behind the development of our next generation HLM, SenTiva and TandemLife products, along with the clinical trials and strategic investments we are making in TRD, TMVR, sleep apnea and heart failure.

Adjusted SG&A expense for the first quarter was $105 million, compared to $97 million in the first quarter of 2018. SG&A as a percentage of net sales was 41.6%, up 290 basis points versus the first quarter of 2018. The increase is largely due to U.S. investments in a DTC campaign for epilepsy, the full impact of including and expanding ACS commercial capabilities, strengthening our commercial organization in international markets and lower than expected overall sales results.

Adjusted operating income from continuing operations was $33 million, compared to $42 million in the first quarter of last year, which reflects the impact of lower neuromodulation sales, while increasing investments in our key growth drivers in R&D. Adjusted operating margin from continuing operations declined 370 basis points to 12.9%. Our adjusted effective tax rate in the quarter was 15.5%, an improvement versus 15.7% in the first quarter of 2018, as a result of ongoing tax efforts. Finally, adjusted diluted EPS from continuing operations in the quarter was $0.54, compared to $0.68 a year ago.

Moving to cash flow. Our cash flow from operations for the quarter ended March 31, 2019 was $2 million. Cash flow from operations, excluding payments for onetime integration restructuring cost, was $30 million. Capital spending for the quarter was $6 million, which was flat versus the first quarter of 2018.

Our cash balance at March 31, 2019 was $51 million, up from $47 million at December 31, 2018. Our net debt at quarter end was $124 million, no change versus year-end 2018. Now turning to 2019 guidance. Given the previously mentioned challenges, we are revising our financial guidance for 2019.

In neuromodulation, we are now expecting a disruption we saw in the U.S. in the first quarter to persist in the current quarter and then gradually improve in the back half of the year. We believe the impact will primarily occur in new patient implants and consequently impact customer buying patterns. Overall, we expect U.S.

neuromodulation to decline to a range of $315 million to $325 million, with the second quarter expected to fall into a range of $70 million to $80 million. In terms of overall guidance, we are forecasting 2019 sales growth of between 1% and 3% on a constant-currency basis. If current exchange rates remain unchanged, the company's full-year revenue guidance would be negatively impacted by 1%. Also note that this guidance includes one quarter of sales from TandemLife prior to the deal closing in April 2018 or $8 million, and the impact of exiting a low margin of OEM distribution agreement in Canada that represented $32 million in sales in 2018.

In order to address the current market dynamics that are impacting our U.S. neuromodulation business while positioning our company for long term growth, we've already begun to advance plans designed to improve profitability in order to offset some of the expected impact. Specifically, we are undertaking plans to optimize expenses across-the-board, reallocating resources to focus on the highest value opportunities within our new product pipeline, redeploying resources investment in talent toward our U.S. epilepsy business to return this business back to growth.

Now turning back to the rest of the P&L. Adjusted gross margin in 2019 is now projected to be in the 68.5 to 69.5 percentage range. In 2019, we expect adjusted R&D to be in the range of 13.5% to 14% of sales and adjusted SG&A to be in the range of 38% to 39% of sales, with TRD having added an additional 50 basis points to each range. As a result of these factors, we are projecting 2019 adjusted operating margin from continuing operations to be in the 16% to 17% range.

Our adjusted effective tax rate for 2019 is expected to be in a range of 16% to 17%. We are projecting adjusted dilutive earnings per share from continuing operations to be in a range of $3 to $3.10, which includes a negligible impact from foreign currency, the previously disclosed negative impact of $0.12 to $0.14 to account for the OEM transition in Canada as well as $0.15 to $0.20 impact from TRD. We assume our share count to be approximately $49 million. While we don't normally provide quarterly guidance, we are providing second-quarter EPS forecast range of $0.60 to $0.70.

Our adjusted cash flow from operations for 2019, excluding integration, restructuring, product remediation and litigation payments is expected to be in a range of $150 million to $170 million. The integration restructuring and product remediation payments are expected to be in the range of $55 million to $65 million. Capital spending is projected to range between $35 million and $40 million, and depreciation and amortization expense is expected to be in the range of $28 million to $30 million. While we are lowering our guidance for 2019, we remain focused on investing in our highest growth opportunities to deliver long term growth.

So with that, I'll turn the call back to Damien for some final comments.

Damien McDonald -- Chief Executive Officer

Thanks, Thad. As a management team, we are looking to build long term shareholder value. I'm proud of the foundation we have built so far. We have transformed LivaNova's portfolio with the sale of our CRM business coupled with investments in our internal R&D portfolio and our recent acquisitions.

At the same time, we have been able to expand gross margins, increase R&D to fuel our pipeline and strengthen our talent and capabilities while our U.S. neuromodulation and Perceval sales fell short of our expectations. Many of our other business lines are performing well, and we have a sense of urgency to course correct these challenges and further streamline our cost structure. Although the results of our efforts will not be visible overnight, I am confident that our focus and attention will return us to our declared aspirations.

We look forward to updating you on our continued progress and delivering on our commitments to drive shareholder value. And with that, Lisa, we are ready for questions.

Questions & Answers:


Operator

[Operator instructions] Our first question comes from the line of Raj Denhoy from Jefferies. Your line is open.

Damien McDonald -- Chief Executive Officer

Hi, Raj.

Raj Denhoy -- Jefferies -- Analyst

Yep, good morning. I want to maybe just start on the VNS line, obviously, probably a lot of questions there. But I guess the -- as you've described the recovery from this Epidiolex issue you've seen so far. How do we get confidence that this isn't going to cut deeper for a longer, in a sense? I mean, there is something that seems different about this drug in terms of people's willingness to try it or their desire to try it? So again, just trying to frame why you think we'll see recovery.

I know you've guided very conservatively here for the second and third quarter, but why do you think we'll see recovery by the fourth quarter and end of 2020?

Damien McDonald -- Chief Executive Officer

Well, I think there's a range of things that we've dug into since we preannounced our sales rise. First is digging into what do we think drove the shortfall. And we -- and our pareto since have advanced, 30% of this was related to Epidiolex, 40% related to our commercial issues and the balance really related to the change in the customer buying patterns. So we're expecting this disruption that we saw in the first quarter to read into the second quarter and then in the second half, start to bounce back.

Q3 being a little stronger and then Q4 returning to growth. So we've broken down the pareto. I think the other thing is -- so we've begun to understand more from customers around Epidiolex, and I think that the trial and evaluation period is like a six- to nine-month period. And I think that also informed us on how we think we're going.

Raj Denhoy -- Jefferies -- Analyst

OK, that's helpful. I guess to that point, 40% of it was sales force turnover, kind of execution on the commercial side. Maybe you could offer something in terms of how you've replaced those folks or how quickly do you think it will be before you can refill the physicians that were lost?

Damien McDonald -- Chief Executive Officer

Yes. So look, we had a slight acceleration in turnover in the third quarter and that impact was really meaningful in two regions. But in a lot instances, we replaced people in the field, many of those with internal candidates. We were able to retain a number of people who were entertaining alternative offers.

So I think that's also been key. But I think the other aspect of this, too, is getting into the commercial execution and making sure that we're focused on sales force compensation, the territory optimization, the communication and positioning messages, those have all been key steps we've taken in the last few weeks to start stabilizing this.

Raj Denhoy -- Jefferies -- Analyst

OK. And maybe just for my last question, I could just kind of ask for a broader one. I think one of the other things that perhaps drove the sharp reaction in the stock on the pre-announcement was kind of the company's communication strategy. You had, I think, been on the road, meeting with investors just shortly before all of this happened and there wasn't any indication that something was going to happen or that, obviously, you couldn't have said much because you were deep into the quarter.

But -- so maybe this -- there's a couple of questions there just about communication and also visibility, I guess, in terms of the business. And why the miss wasn't known until very late, late in the quarter, at least things weren't tracking as you expected until very, very late?

Thad Huston -- Chief Financial Officer

Yes, Raj, it's a very fair point. Clearly, we typically see that the quarter sales cadence is definitely skewed toward the end of the month for our neuromod business, and we were surprised by the -- we didn't see that pick up in the last week. And so when we were out talking, of course, we were -- we'll describe where we were at that point in time. But we did see that deviation in the trends that occurred really toward the back end of the quarter and that created a challenge for us, and that's why, we -- as soon as we had clarity on the sales results, we started our efforts to publicly communicate and that's why we did the pre-announcement.

Raj Denhoy -- Jefferies -- Analyst

So how much of VNS revenue then does fall in the last week or so, two weeks of the quarter, typically?

Matthew Dodds -- Senior Vice President of Corporate Development

So -- it's Matt. We won't give you the last couple of weeks. But for the last month, it's about 50% for the quarter, generally in every quarter.

Raj Denhoy -- Jefferies -- Analyst

OK. That's fair. I'll leave it there. Thank you.

Damien McDonald -- Chief Executive Officer

All right. Thanks, Raj, too.

Operator

Our next question comes from the line of Rick Wise from Stifel. Your line is open.

Rick Wise -- Stifel Financial Corp. -- Analyst

Hi. Good morning.

Damien McDonald -- Chief Executive Officer

Good morning, Rick.

Rick Wise -- Stifel Financial Corp. -- Analyst

Can you give us a little more color, Damien, on the U.S. Perceval weakness? And as -- you sort of spelled out a little more detail on the neuro side and what you're doing and the sales, I'm not as clear about what's happening there. I mean clearly, Perceval is doing great OUS. Just talk about the leadership changes that you've made? And help us think through there the cadence or that drivers of improvement as the year unfolds.

And maybe what you assume to route that?

Damien McDonald -- Chief Executive Officer

Right. Yes, we put in a new leadership structure around Q4 last year. The diagnosis, I think, is reasonably clear with them. They've dug in much more, especially these last three months.

And I think for us, this really relates to a few things. And I will say and we said in the script, it's commercial execution on our part. We don't believe any of this had to do with a meaningful change in the perception of low-risk TAVR. Our plan is around better commercial execution, better procedure training, both of our internal people, as well as the accounts that we're supporting.

The valve-in-valve indication, I think, is a meaningful change in the communication plan as well as the 10-year data. And we'll be implementing more discipline around the, what we call, daily management for the sales force execution there. What many would just refer to as sales 101 that were really not in place that Rich and team are really starting to execute on that now.

Rick Wise -- Stifel Financial Corp. -- Analyst

And again, just as you reflect on -- I mean, does this take a full year to make all these things happen, Damien? Or do you think we can sequentially imagine improvement now that you're focused on it in each quarter? Or no, its back half loaded? Again, if you could frame that that would be helpful.

Damien McDonald -- Chief Executive Officer

Yeah. I think you stabilize that in Q2 and then you start building in the second half. By that time, you start getting traction in the accounts. And there's two parts of this: The account acquisition, finding new accounts; and then account penetration.

And both of those things, coupled with these internal efforts, I think we'll take a few quarters to read through it.

Rick Wise -- Stifel Financial Corp. -- Analyst

And Damien, going back to neuro. Just, can you help us understand what you've -- you talked about the breakdown of the headwinds in neuro short term. I wonder what you assumed in terms of the -- on the Epidiolex side. What have you assumed about trialing or maybe de novo neuro implants going to drugs out of the gate, as you trial.

How are you -- what changed in assumptions and what are you assuming now going forward?

Damien McDonald -- Chief Executive Officer

The big thing for us is we really looked at this and our key opinion leader and neurosurgeon, neuroscience input said, look, this looks a lot like another drug. The 12-week trial that's an acute therapy. Its relatively expensive, limited indication. So this looks like drugs that we've seen in the past four to six months.

What I think we were really caught off guard by was the enthusiasm for things that are -- anything cannabis. And you probably know as much as anyone that there's a lot of noise and enthusiasm for that. And what we've really begun to understand is maybe this is more like the six- to nine-month program, by the time people try it, see what the effects are. Again, our pipeline of -- the start of our funnel, the patient identification, was really robust.

What we saw was the slowdown in the movement of people from patient ID through the implant. And so that's where our -- probably our systems or process or methodology for analyzing, it was slightly off, just that timing and what it would do to the conversion from ID through implant.

Thad Huston -- Chief Financial Officer

Yes. Clearly, we were also -- Rick, I wanted to provide more clarity around the U.S. kind of phasing as we were surprised in Q1, we also have a -- described a range of $70 million to $80 million in Q2 for U.S. neuromod.

And then clearly, as we go onto the back half of the year, we still have an impact forecasted. But that's again why we provided a full-year range as well.

Rick Wise -- Stifel Financial Corp. -- Analyst

Right. And just one last for me. I'm sure, I'm -- I would be astonished to think that you weren't trying to be incredibly conservative as you reset the bar here. But can you help us think through your guidance here? Are you thinking, hoping this is conservative and working hard to make it better? Or no, this is realistic, would you hope it could be better than this? And maybe, Damien, at high level, help us think through what might make it better? I mean you have a lot of new products in the pipeline in the basic business, SenTiva 2.0, HLM, Tandem.

I mean, where would the do a little better side of things come from? Thanks so much.

Damien McDonald -- Chief Executive Officer

So this is where an old mentor, several of us, which I hope is not a strategy. Our key activity here is focusing the U.S. sales force on execution, giving them the resources to be more effective. So that's why we came back to the product messaging with the field training and our account acquisition and penetration.

Moving patients through from identification to implant is really key here. So I think we've been prudent in the guidance. This is our best estimate of how the year looks. And our intention is to work our plan now.

Rick Wise -- Stifel Financial Corp. -- Analyst

Thank you very much.

Operator

Our next question comes from the line of Matthew O'Brien from Piper Jaffray. Your line is open.

Matthew O'Brien -- Piper Jaffray -- Analyst

Good morning. Thanks for taking the question. So as we think about the business from here given the shortfall in Q1 and the adjusted guidance here, I think what most people are trying to get a sense for are a couple things, and I'll break up the question. The first piece would be, as we base here for the core business and then hopefully improving the second half of the year, with all the spending that's going on.

How do we think about the business as we exit this year and then we get into 2020? Because, obviously, this a soft year and then an investment year. So how do we think about the business unfolding late this year into 2020 in terms of top-line growth plus potential leverage to the bottom line?

Thad Huston -- Chief Financial Officer

Yeah. Thanks for the question. It's clear that we wanted to better understand the impact on the neuromod business and that's, again, why we provided a revised guidance. We're not in a position to provide 2020 guidance at this point.

But clearly, we'll provide updates as we go throughout the year and as we get closer, give more of a line of sight on. Frankly, the biggest driver, which is how our growth is projecting, particularly in U.S. neuromod. So we need a few quarters, obviously, to understand the impact of both Epidiolex and also the field dynamics that we've described.

Damien McDonald -- Chief Executive Officer

So -- and in terms of the P&L, what we've indicated, too, is we're going to be making changes in our cost structure to be more prudent there. So I think we're pretty transparent about that. Having said that, what we've ringfenced is a lot of the growth program and the R&D. So leading into later this year, with the Delta program for ACS, just to come back on the previous question from Rick as well.

We've got that in the pipeline. We've got -- really, I think a lot of opportunity to talk about the Perceval with the valve-in-valve. I think that opens up a lot of opportunity for us. And then heading into next year, it's a next generation heart-lung machine as well as SenTiva 2.0.

So we've really ringfenced the key near-term opportunities. And a very big focus for us is bringing depression into commercialization and that is progressing well. And we're still anticipating our start of our programming in Q3. So, the idea for us is let's make sure we stabilize the base and get the core growing again.

Let's make the right cost decisions in the middle of the P&L. Let's make sure it ringfences the near-term and key growth drivers. And that's our playbook.

Matthew O'Brien -- Piper Jaffray -- Analyst

Make sense. Would you get aggressive with the balance sheet to offset the lack of leverage maybe later this year, even into next year in terms of buying back stock?

Thad Huston -- Chief Financial Officer

Yeah. I think we've always looked at the balance sheet and obviously, our capital allocation plans. I mean, clearly, where we are today. We have to also look at addressing this 3T liability and that's one of our priorities.

But we will look at everything.

Matthew O'Brien -- Piper Jaffray -- Analyst

OK. And then the other question for me is, again, all the investment this year, you're sticking with your pipeline and really trying to be aggressive there. So I know we're only three months after you gave us an update last quarter. But given all that investments, what have you seen in the last three months that gives your more confidence, either in the existing pipeline via heart failure or TRD, mitrals, whatever it may be or even on the circulatory support OUS.

Anything along those lines you can point people toward as we transition through this investment year here in '19 and look into '20 and beyond.

Damien McDonald -- Chief Executive Officer

Yes. Look, I think a few things. In terms of -- we've talked about the LivaNova business system and we've really very much isolated these issues, U.S. and particularly, neuromodulation, the epilepsy and Perceval.

The growth in the other regions, Europe and international, that has been really strong. So I think that's a positive for us. We recently reviewed the next generation heart-lung machine program in a big dive with that team, very happy with the progress they're making. The Delta program, which is the project name for the next generation ACS device, which is the pump and monitor, is progressing well.

We're really encouraged by the VITARIA, the heart failure recruitment, that's really, again, as we mentioned, ahead of expectations there now and coming around on 100 patients randomized. And 300 patients is the point of the -- the functional end points, so we'd be submitting the PMA. So that's progressing well. The TRD program, while we're finishing off negotiations with CMS, we have begun in parallel recruiting sites.

We can't go through IRB without a finalized protocol, but we're doing everything up to that point. And I'm really impressed with the focus in the business discipline that that clinical team has implemented there. So I think there are a number of things that we're really pleased with the progress. Lastly, just to reference on Caisson, that we've really identified that the single issue here is about the anchor design.

The team have really made a tremendous progress on coming a round to finalize two potential designs. They're going to try to narrow it down in the next month or two and then now go into the cycle of testing on that. And we expect to be back in recruiting for the trial in the first half of '20. So I think that's a bit of a list of things that we think are continuing to operate well.

Matthew O'Brien -- Piper Jaffray -- Analyst

Got it. Thank you.

Damien McDonald -- Chief Executive Officer

Thanks, Matthew.

Operator

Our next question comes from the line of Scott Bardo from Berenberg. Your line is open.

Scott Bardo -- Berenberg Bank -- Analyst

Yes, thanks for taking my questions. So on VNS, I think the narrative has always been that the penetration opportunity is quite significant even in the U.S. market, where I think you've called out around 5% of the addressable new patients for a drug resistant epilepsy getting VNS therapy, which makes it somewhat surprising that Epidiolex causes such a material and surprising impact to your business, given the narrow indication of that product. So what I want to understand is, your guidance now for the second quarter for U.S.

neuromod, if I understand correctly, is highlighting a negative 10% to 20% full in your U.S. neuromodulation business. I mean particularly in keeping with the mindset that you have some regular business, if you like, or you have a replacement business here would imply that new patient adds grind to a halt. So I wonder if you could sort of square the circle for me and with respect to the penetration opportunity and why all of a sudden no new patients are going on VNS therapy in the U.S.? And just help me understand really what forms this, particularly with the mindset that half of yourselves are coming in the last few weeks in this business? So that's question number one.

I have two follow ups. Thanks.

Damien McDonald -- Chief Executive Officer

OK. So a few things. You're right. I mean the end of service numbers for us still varies there.

The slow for us is in the new patient -- identification on new patients implants. And for us, yes, you're right, the penetration is relatively low. There's still lot of drug-resistant epileptics coming into the funnel every year. But you've got to move those patients through a process with a combination of neurologist, neurosurgeon or another implant or like an ENT in the big centers -- it's a panel of people.

And again, we were surprised and what messed that model up is just the enthusiasm for everything cannabis. And we can see a meaningful difference between a number of prescriptions written and a number of prescriptions filled for Epidiolex. So we believe that the patients are in that pool delaying the decision about an implant. So now we get back to competitive positioning, which is -- we've got a series of messages that I think we have to be more aggressive about in terms of the benefits of drug plus VNS, whatever drug, Epidiolex or whatever.

And as I said, I mentioned that is one of our countermeasures to start this with me. And so yes, it is new patient implants. It's in a very focused number of centers. And we've got work to do.

Thad Huston -- Chief Financial Officer

Yes, I would add that I do think it's prudent for us to think about the bowl of the patients that are essentially affected by this new drug launch, and to look at the first half of the year and to assume that there's going to be a reduction in new patient implants, at least temporarily. And then as we kind of look at the rest of the year, that it would gradually improve through the back half of the year. And so kind of picturing a dip and then an improvement overtime. And that's kind of how we've been thinking about it and understanding it.

You also have then an impact on just kind of customer buying patterns until they understand those kind of -- there was an impact on the NPI, there's an impact on the amount that's being purchased.

Scott Bardo -- Berenberg Bank -- Analyst

Understood. And you're highly confident that there has been no stuffing of the channel or excess inventory in your hospitals and this is just in part a normalization of stock. You're very confident that there's no excess stock in the market, this is really end market demand trends you're seeing here?

Thad Huston -- Chief Financial Officer

Yes. If you're implanting as an account, a few less patients, I think that's natural that the buyers look at their par levels and say, what we need to buy this month. And again, that's what caught us in the quarter and that last month. We just didn't see that the customer buying patterns as normal.

Damien McDonald -- Chief Executive Officer

And it's still our place. I mean when you talk about IPGs and pacemakers, spinal cord stem. When the market's slow, you've seen impact to how much a customer will hold based on the unit demand.

Scott Bardo -- Berenberg Bank -- Analyst

Understood. So second question, please. Clearly, not great to be cutting guidance only a few months after setting it. You've decided to stick with meaningful investments into your pipeline.

So I think given the obvious impact that this is having on near-term performance, could you please give us some sense as for the main full projects, sleep apnea, mitral, TRD, heart failure, how much are you investing actually, across the P&L? And maybe give us some sense of time frame, when you expect these assets to materialize that would help if you like balance some of the investments with some of the opportunities.

Thad Huston -- Chief Financial Officer

Right. So as you point out, we are in this guidance, continue to maintain our investment in our innovative R&D pipeline. So we think that we have some really exciting opportunities clearly with TRD, with heart failure, with sleep apnea, with Caisson. Clearly, they kind of all come in this different time horizons.

And clearly, heart failure and actually TRD are more near term and then sleep apnea and then Caisson, it's for further out. We spend roughly half of R&D in our innovative pipeline. And so I think that is one of the things that makes us very unique versus a lot of other companies in the space. But when you look at the number of cents or the amount of cents that we're spending.

We're spending roughly $0.70 on our innovative pipeline. And that is a choice that we're making and it is roughly similar, I mean, $0.10 to $0.15 per item that we have in our pipeline on an annual basis that we spend. And so I could provide more detail. But clearly, we believe that these things are prudent investments, investments that are going to ultimately drive the long term success.

But we'll also look at all these pipeline opportunities and balance those choices.

Damien McDonald -- Chief Executive Officer

And then a proportion of the other half is spent on the organic pipeline, the Polaris program, for the next generation heart-lung machine, the ACS Delta product and SenTiva 2.0. So again, it's a -- the strategic priorities or strategic projects that we've talked about, the big four, as well as lead internal programs that we kicked off in, roughly 18 months ago.

Thad Huston -- Chief Financial Officer

Yes. The excitement that we have around TandemLife and then obviously, a next-generation HLM and a next-generation SenTiva will really carry us into 2020 and beyond.

Scott Bardo -- Berenberg Bank -- Analyst

That's helpful color. And sorry, just lastly on this then. I'm also assuming that -- and there's been some additional SG&A investments related to this decline. A 40% SG&A ratio is quite astonishing.

So could you give us a sense of how much of your SG&A ratio relates to these pipeline assets as well?

Thad Huston -- Chief Financial Officer

Yes. So clearly, SG&A has been moving up. And part of the reason it's moved up is that we have made strategic investments in really neuromodulation, particularly, the direct-to-consumer promotion campaign as well as rest of world global expansion, as well as now we're bringing on TandemLife AGS to our portfolio and we doubled the sales force last year. So we have stepped up the investment on our priority areas.

Clearly, as that approach is 40% that becomes a high water mark, I would say, and one where we have to offset and make some other choices within our expense portfolio. So we are optimizing expenses. We're reallocating resources, in many cases, from cardiac surgery to neuromodulation. We are we redeploying investments to support epilepsy.

It is roughly $0.15 of our guidance is coming from these expense cuts. We're ringfencing the R&D programs, and then geographic expansion, we think, is important. But we're cutting in other areas to help mitigate at least some of this downside.

Scott Bardo -- Berenberg Bank -- Analyst

Got it. I'll jump back in the queue. Thanks, guys.

Damien McDonald -- Chief Executive Officer

Thanks, Scott. Cheers.

Operator

Our next question comes from the line of Matt Taylor from UBS. Your line is open.

Matt Taylor -- UBS--Analyst

Hi, thanks for taking the question and good morning.

Damien McDonald -- Chief Executive Officer

Good morning.

Matt Taylor -- UBS--Analyst

So I just wanted to ask a follow up question on the dynamics with Epidiolex that you called out. There's been some prior cases of drug launches in the past that you can compare this to. Could you walk us through any color comparisons or qualitative comparison from those launches? And how do they inform your view of what's happening here with Epidiolex?

Melissa Farina -- Vice President of Investor Relations

Sure. Hey, Matt, it's Melissa. The last most comparable launch would be launch of [Inaudible] in June of 2009, and during that time frame, we saw approximately a two-quarter impact to new patients. So that drug was significantly different than Epidiolex, has launched as a very generalized indication.

We do, as we mentioned previously, expect the impact of Epidiolex to be slightly longer to adjust the time frame it takes to receive a prescription because of scheduling. But other than impact, it's quite similar on a percentage basis.

Matt Taylor -- UBS--Analyst

OK. And then with regards to the commercial disruption that you called out in neuromod. Could you talk a little bit more about what the plans are to make sure that that gets better? And if you're losing some reps, is this a change in the market or it was just kind of a one-off event that happened together? And could you give us any color on where you might be losing folks, too?

Damien McDonald -- Chief Executive Officer

Yes. I think it was a confluence of events. You had the Epidiolex timing at the same time as some competitive hiring. Some of them did go to GW Pharma and I think they make fairly compelling offers through them financially.

Having said that, I think we were able to retain a number of people, and I think our value proposition or patient proposition is a -- it's something that goes beyond just compensation. And I think being able to explain that was a key part of it. Having said that, we have -- we're looking at the sales force compensation, and have implemented changes already for this quarter and beyond. And we're looking at territory optimization, which is as a key step that we're taking.

We're looking at a competitive positioning in the story we're telling and how we tell that story. So I think all of those things are going to help us readjust the sales force and commercial disruption. As we said, we're on top of where Melissa was with how do we deal with the timing of Epidiolex.

Matt Taylor -- UBS--Analyst

Great. Thanks a lot for the color.

Damien McDonald -- Chief Executive Officer

Cheers, Matt.

Operator

Our next question comes from the line of Mike Matson from Needham & Company. Your line is open.

Mike Matson -- Needham and Company -- Analyst

Morning. Thanks for taking my questions. I guess just want to start with opex guidance. So on a dollar basis, Thad, maybe you can comment on SG&A and R&D spending on a dollar basis.

Is that expected to be up or down versus your prior plans?

Thad Huston -- Chief Financial Officer

So SG&A is clearly going to be down and roughly $0.15 of EPS to kind of mitigate what is roughly about $0.75 of the EPS impact due to the sales shortfall that we're calling out here. So we're covering a portion of that. We are, as I mentioned earlier, ring-fencing the R&D programs within our guidance at this point. We will take a deeper look at R&D and see what we can do to further optimize the spend there.

Mike Matson -- Needham and Company -- Analyst

OK. And then given the issues in the neuromodulation business, are you planning any changes to the DCC efforts there? Are you going to increase it, decrease it, maintain it in the shorter term?

Thad Huston -- Chief Financial Officer

I think for the most part, we're kind of continuing with our plans, but what we are looking at, better understanding the pull through. So we've increased the number of patients into the funnel. And so we're pleased with the results but it's still early. So we're kind of closely monitoring that and phasing some investments, blowing down some other things til we have a deeper understanding of the results.

Damien McDonald -- Chief Executive Officer

And as we mentioned, we're looking at our competitive position in how we're telling a story versus the drugs plus VNS and why it plays a critical part of the thought process, not as an afterthought.

Mike Matson -- Needham and Company -- Analyst

Sure. And then just with the gross margin guidance, I guess, I'm a little surprised, it was only down 50 basis points from previously, just given the high margins on the neuromodulation products? So are you offsetting some of the impact somehow or?

Thad Huston -- Chief Financial Officer

Yes. So the good news is that we have seen, and continue to see really great momentum in ACS.

Damien McDonald -- Chief Executive Officer

In ACS.

Thad Huston -- Chief Financial Officer

Yes, on ACS, but also just generally the mix of our business. And we are also seeing SenTiva as a percentage of total neuromod implants also improve as a percentage overall. So we think the SenTiva could reach 70% to 75% of total generator sales. So price is holding up.

Overall, regional mix is strong. So although we took normalized sales down, we still feel confident about that range that we provided.

Mike Matson -- Needham and Company -- Analyst

OK. Great. Thanks a lot.

Damien McDonald -- Chief Executive Officer

Thanks, Mike. Cheers.

Operator

Our next question comes from the line of Jason Mills from Canaccord Genuity. Your line is open.

Jason Mills -- Canaccord Genuity -- Analyst

Hi, Damien, Thad and Matt. Thanks for taking my questions. Damien, I wanted to go back to the questions about neuromodulation, the drivers of the impact there. And specifically, the sales force.

Look, I have a hard enough time climbing in my own mind. But I'm going to ask you to help us understand the calculus of maybe going through some of the minds of these reps that are leaving. And the dynamic, as I look at it, is you're portraying it from an opportunistic standpoint, is you have still a big opportunity in TRE and a pending opportunity that's a two-part with TRD. So why are these -- the question is just why are these reps leaving? Is it truly in your mind a near term comp issue? And then as a related follow up to that question.

It doesn't seem like something or driver that would be a surprising, sort of, end of quarter situation or why is it? Could you give us some help there on the calculus of reps leaving? It seems like -- it implies that they think it could be longer term.

Damien McDonald -- Chief Executive Officer

Well, I'll come around on that second part first. And what surprises us, a few reps did leave in the quarter and they were particularly high profile reps. A significant amount of revenue dried up with their exit in the quarter. You change the patient dynamic as well as the ordering, purchasing from their specific accounts.

So in the quarter, that was a definitive issue for us. And the bigger issue is, for us, the whole competitive landscape has really amped up. And we've found a lot more competitive hiring, not just in epilepsy, but in implantables. And so we saw an uptick in turnover in again, a few key regions.

So those are the things for us that really, really ticked up. Now what do we need to do better? We need to really dive into compensation and territory optimization. Do we need to make some changes to the way territories are aligned and supported? We've already made changes in the compensation and made at all three levels of the area direct to the regional manager and the sales people. So I think that's the key thing.

We also look at what resources we're giving them and how they can be more effective. And are those the things that were causing them to think about alternatives, where I could go to a job that had better resources or better support. So we believe on the first compensation changes, we've made great progress. We've got work to do on the support and the messaging and that's one of the other key sets of programs that we're leaning into.

Jason Mills -- Canaccord Genuity -- Analyst

OK. Thanks for that. And then as a follow up to that. Could you just talk about in general the neuromodulation sort of marketplace? And as you think through some of these dynamics that are impacting the business in addition to some of the things you're talking about putting in place, could you talk about just the cadence as you roll through the year, because if you've got a six- to nine-month sort of trialing period as you've pointed out with the drug, and you also have difficult comps -- more difficult comps through the U.S.

neuromodulation business in the second half of the year. Is it reasonable for us to expect that organic growth in the second half of the year will actually tick up? It seems like some of them, a precarious place to be modeling growth to tick up against the difficult comp given that you're still be sort of overlaying some of the trialing periods that you pointed out. Thanks for taking the question.

Damien McDonald -- Chief Executive Officer

Yes. [Inaudible] I want to say a few things. You're coming on guidance now. But i just -- look, first of all, the number of reps we're talking about isn't the entire sales force.

We've got a bunch of really talented people who are very committed to the patient messages that we have. So we've got a sales force that has still lots of opportunity, and I think that the people that have stayed see that and we're going to continue to work with them again. Compensation is one part of it, but tools and messaging, I think is really key. And so we've been very prudent with, I think, the guidance saying that where we think to do it and that $70 million to $80 million range.

And what we're saying about the full year was the $315 million to $325 million, and I mean, we're also trying to let people understand that it's largely going to continue in Q2 -- again, we've given the future number, which is unusual for us. But we also wanted to be clear that's why we think it's going to look different in the back half of the year.

Thad Huston -- Chief Financial Officer

I think to me and again, we recognize we've surprised the market in Q1 with the results. And so providing the range of $70 million to $80 million provides the baseline for what we think the impact will be of this Epidiolex effect. And then as you look at the back half of the year, showing an improvement versus Q2, but still a decline versus probably prior-year NPI, was kind of how we're thinking about it from a forecast perspective and that's how we get to this $315 million to $325 million overall annual U.S. neuromod sales.

Jason Mills -- Canaccord Genuity -- Analyst

OK. Thank you, guys. I'll get back in the queue.

Damien McDonald -- Chief Executive Officer

Thanks, Jason. Cheers.

Operator

Our final question today comes from the line of Scott Bardo from Berenberg. Your line is open.

Scott Bardo -- Berenberg Bank -- Analyst

Hello, again. Thanks very much for taking the follow-up. So I mean, just a discussion on the heart valve business and clearly, this has not been performing, not just the last few quarters, but I mean honestly, the last 10 years or so. So I guess, the question I have is what makes you convinced that LivaNova is the right owner for Perceval and the structural valves franchise? And as a follow on, can you operate in mitral valve if you don't have structural valve for the new portfolio? Thank you.

Damien McDonald -- Chief Executive Officer

Hey, Scott, great questions. Look, first of all, this is the second part. First, yes, the answer is yes, it's a different call point, different disease -- in some instances, there are panels, where you got the entire cardiac group. But we largely believe that that call point is a different one between the surgical and the transcatheter.

Look, I would point you back on the heart valve business to the last two years. We've largely transformed the portfolio. We've been able to make changes across the board. We've exited some businesses, doubled down in others.

And so that transformation, I think, has progressed well. We've built this robust pipeline, which is, I think, really going to read through mostly starting later this year into next year. And lastly, really focused on key issues and we intend to fix them. One of those things, the Perceval business.

So I think we've been very clear that the traditional surgical valves are probably going to -- head toward 0 and really, the guiding net part of the portfolio wasn't ever our intention, stabilizing mechanical while getting Perceval growing was a key opportunity for us. And I do see a number of our sales people in the commercial teams being able to execute what I consider benchmark performance. We're seeing strong growth in parts of the world in international and Europe. We've got reps in the U.S.

who are performing brilliantly. Focusing on them, giving them the resources and the things that I talked about, the procedure training, better indications to talk about better data, the 10-year data. Now we've got reimbursement in Japan, commercializing in Japan.

Thad Huston -- Chief Financial Officer

And the valve-in-valve.

Damien McDonald -- Chief Executive Officer

And the valve-in-valve, right? So the history of our last two years is, transform the portfolio, build the pipeline, focus and fix. And that's our intention with this part of the portfolio, too. But you'll know that we will make the tough decisions when we need to.

Scott Bardo -- Berenberg Bank -- Analyst

Understood. And last one, please. I've always argued that in your neuromodulation business, growth is also pretty aligned to product cycles and clearly, here we are in a year where growth is pretty subdued and we've haven't got an imaginary introduction of a product. So with that mind, can you lift the curtain a little bit on SenTiva 2.0? Is that an evolution or revolution? Or how should we be thinking about that into next year to give us some comfort there, these sorts of growth impacts are transient? Thank you.

Damien McDonald -- Chief Executive Officer

Well, I think two things. I'm a believer, too, that SenTiva is a -- was a significant opportunity. And 18 months or 24 months cycle isn't anywhere near long enough to fully exploit the benefits of that cycle. I think we've got plenty of runway with SenTiva.

Having said that, 2.0 is I think going to be really an impressive change. It's got the Bluetooth capability that the team is developing and the ability for the product to communicate into the cloud. And when you talk to patients, the big issue is empowerment and we think that being able to give them more access to information, it's going to empower them. And I think from the clinical side, being able to access the data and do more with the data and not necessarily have the patient coming into the clinic, is also going to be powerful.

So we believe, there's a lot of upside in that unit. And this is why we believe, our investment in digital innovation is really key here. It's a major opportunity for us.

Scott Bardo -- Berenberg Bank -- Analyst

Got it. Thanks very much, Damien.

Damien McDonald -- Chief Executive Officer

Thank you, Scott.

Operator

We have no further questions in queue. I'll turn the call back to the presenters for closing remarks.

Damien McDonald -- Chief Executive Officer

Well, thank you, everyone. Again, we know that the Q was not the sort of numbers that you wanted us to print, nor was it the numbers we wanted to print. We've been focused on transforming the company over these last two years. We've built a robust pipeline and we are intent to focus and fix the issues that we've spoken about.

So thanks for your questions, and we look forward to those conversations with you. On behalf of the whole team here, thanks.

Thad Huston -- Chief Financial Officer

Thank you.

Operator

[Operator signoff]

Duration: 64 minutes

Call participants:

Matthew Dodds -- Senior Vice President of Corporate Development

Damien McDonald -- Chief Executive Officer

Thad Huston -- Chief Financial Officer

Raj Denhoy -- Jefferies -- Analyst

Rick Wise -- Stifel Financial Corp. -- Analyst

Matthew O'Brien -- Piper Jaffray -- Analyst

Scott Bardo -- Berenberg Bank -- Analyst

Matt Taylor -- UBS--Analyst

Melissa Farina -- Vice President of Investor Relations

Mike Matson -- Needham and Company -- Analyst

Jason Mills -- Canaccord Genuity -- Analyst

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