November 2, 2026
On October 28, Boston Scientific lowered its 2026 guidance for the third time this year. The company now expects full-year revenue growth of 4.25%, down from the 10.5% to 11.5% it projected at the start of the year (MedTech Dive).
One of the biggest reasons is Watchman, the company's left atrial appendage closure (LAAC) device. Watchman sales fell 6% in the third quarter, after growing by nearly 30% in 2025. CEO Mike Mahoney told investors the slowdown came from changes in patient identification and referral patterns.
That explanation matters well beyond one company. Watchman did not lose a head-to-head battle for implanting physicians. The slowdown happened earlier, at the point where patients are identified and sent to a specialist. For a referral-dependent device, that upstream funnel decides growth as much as the procedure room does, and it calls for a different kind of commercial team.
Watchman's US growth stalled in 2026 because fewer standalone patients reached implanters, not because implanters switched devices. The numbers show the shift quarter by quarter.
In March, Boston Scientific's CHAMPION-AF trial met all of its primary and secondary endpoints, comparing Watchman FLX with blood thinners as a first-line option. The company said it would use the data to seek a wider indication and coverage.
By the second-quarter call on July 29, the picture had changed. Watchman grew 4% globally and only 3% in the US (MD+DI). Mahoney said about one-third of US Watchman procedures were now done concomitantly, alongside an ablation. Concomitant procedures grew more than 60%, while standalone procedures, the other two-thirds, fell by low teens year over year.
Mahoney gave two reasons. First, a large amount of new clinical evidence on stroke risk in atrial fibrillation had been published over the previous nine months, and absorbing it into practice was affecting patient identification and referral patterns. Second, the rapid shift to concomitant procedures had created inefficiencies in how hospitals run standalone and concomitant cases side by side.
In the third quarter, Watchman sales fell 6% (MedTech Dive). Competition is also coming: Edwards Lifesciences received FDA clearance for its Ecliptis left atrial appendage exclusion system in late June, and Mahoney said he expects some share erosion in 2027.
In a referral-dependent category, the physician who implants the device is rarely the one who first sees the patient. Growth depends on many other clinicians recognising a candidate and sending them on.
Boston Scientific's own recovery plan shows where it thinks the problem sits. After the July call, its first priority was expanded physician education to help both referrers and implanters identify appropriate patients. The second was investing in its commercial organisation to increase account engagement, and the third was direct-to-patient investment to reach more patients at the start of their care journey (MD+DI).
This creates a commercial risk that procedural sales alone cannot fix. When new evidence makes referrers less certain which patients are appropriate, referrals slow, even if implanters stay loyal and the clinical case remains strong. Boston Scientific's chief medical officer Ken Stein said on the July call that 30% to 40% of AF patients who need stroke prevention currently receive nothing (MD+DI). The demand exists; the bottleneck is getting those patients identified and referred.
The same pattern applies in other referral-dependent categories. In TAVR, for example, Edwards Lifesciences describes patients moving through a Heart Team referral pathway before treatment. In each, growth is decided before the patient reaches the procedure room.
In our view, a referral-dependent business needs five capabilities beyond the territory manager and clinical specialist who support cases. Each maps to a point in the funnel where patients can be lost.
Therapy and referral development managers. These roles work upstream of the procedure, with the physicians who find and refer patients. An Edwards Lifesciences Therapy Development Manager posting for its TAVR business in Kansas City shows the shape of the job. It asks the hire to understand referral dynamics, find where patient access is restricted or delayed, and assess the diagnosis and treatment funnel in a territory. It requires at least eight years of experience, including commercial clinical sales or pharmaceutical sales.
Medical education and medical affairs. When new evidence unsettles referrers, someone has to explain what it means for patient selection. Boston Scientific's first Watchman priority was exactly this: physician education and evidence dissemination. Medical science liaisons and clinical education managers who can talk credibly to general cardiologists, neurologists and primary care physicians become central to growth.
Patient activation and direct-to-patient marketing. Boston Scientific is accelerating direct-to-patient investment to stimulate demand. That requires marketers who can reach patients compliantly and guide them towards a specialist conversation.
Account and program development. Mahoney said the fast shift to concomitant procedures created inefficiencies in running standalone and concomitant cases. Account managers who understand hospital workflow, scheduling and service-line economics help sites run both models without one crowding out the other.
Market access and reimbursement. Boston Scientific said it will use CHAMPION-AF data to seek a wider indication and coverage. BTIG analyst Marie Thibault has pointed to label expansion and a revision of Medicare's national coverage determination as potential upside. Reimbursement and health economics specialists will shape how quickly any wider eligibility turns into referrals.
For commercial leaders, the lesson from Watchman is to staff the funnel before it stalls. Referral development, medical education and patient activation are often added once growth slows. By then, the referral habits that drove early growth may already have shifted.
Hiring managers should look for people who can diagnose where patients are being lost, not only close business with implanters. Useful signals include experience mapping referral networks, working with non-implanting specialists, and turning new clinical data into clear patient-selection messages. Pharmaceutical sales experience can be relevant here, as the Edwards posting recognises, because pharma reps are used to calling on referring physicians.
For candidates, these roles offer a path into high-growth device categories without a pure quota-carrying procedural sales background. Clinical specialists, educators and pharma reps with cardiology or neurology experience are well placed. The strongest candidates will be able to show how they moved patients through a pathway, not just how many cases they supported.
Watchman's slowdown shows that a strong device and a loyal implanter base are not enough on their own. In referral-dependent categories, growth is won or lost upstream, in how patients are identified and referred. Companies that treat that funnel as a core commercial function, and hire for it, will be better placed when the next wave of clinical evidence or competition arrives.
At 44 International, we help US MedTech companies build commercial teams across the full patient pathway, from therapy development and medical education to market access and field sales. If you are building or rebuilding a referral-dependent business, we would be glad to talk.
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