Earnings Call
Cytosorbents Corp (CTSO)
Earnings Call Transcript - CTSO Q4 2022
Operator, Operator
Good afternoon, and welcome to the Cytosorbents Fourth Quarter and Full Year 2022 Financial and Operating Results Conference Call. At this time, all participants are in a listen-only mode. Following the formal remarks, we will open the call for questions. Please be advised that the call will be recorded at the company's request. At this time, I'd like to turn the call over to our moderator, Jodi Hoover. Please go ahead, Mrs. Hoover.
Jodi Hoover, Moderator
Thank you, and good afternoon. Welcome to the Cytosorbents fourth quarter and full year 2022 financial and operating results conference call. Joining me today from the company are Dr. Phillip Chan, Chief Executive Officer; Vincent Capponi, President and Chief Operating Officer; Kathleen Bloch, Chief Financial Officer; Dr. Efthymios Deliargyris, Chief Medical Officer; Dr. Christian Steiner, Executive Vice President of Sales and Marketing and Managing Director of CytoSorbents Europe GmbH; Christopher Cramer, Senior Vice President of Business Development and Dr. Irina Kulinets, Senior Vice President of Global Regulatory. Before I turn the call over to Dr. Chan, I'd like to remind listeners that during the call, management's prepared remarks may contain forward-looking statements which are subject to risks and uncertainties. Management may make additional forward-looking statements in response to your questions today. Therefore, the company claims protection under safe harbor for forward-looking statements contained in the Private Securities Litigation Reform Act of 1995. Actual results may differ from results discussed today, and therefore we refer you to a more detailed discussion of these risks and uncertainties in the company's filings with the SEC. Any projections as to the company's future performance represented by management include estimates today, as of March 9, 2023, and we assume no obligation to update these projections in the future as market conditions change. During today's call, we will have an overview presentation covering the operating and financial highlights for the fourth quarter and full year 2022 by management. Following that presentation, we will open the line up to your questions during the live Q&A session with the rest of the management team. And now it's my pleasure to turn the call over to Dr. Phillip Chan.
Phillip Chan, CEO
Thank you very much, Jodi, and good afternoon, everyone. For the first slide, I'd like to just cover some recent operational highlights. First of all, we ended last year with more than 195,000 cumulative CytoSorb treatments delivered as of the end of the year, up 20% from the end of 2021 and marking 10 years of CytoSorb commercialization. Second, our STAR-T pivotal trial passed the halfway point of enrollment with an acceleration of enrollment aided by the addition of new Canadian sites following Health Canada approval of this study. We are on target to achieve 80 patients by spring of 2023 and complete enrollment of the study by the summer of 2023. We also added Dr. Richard Whitlock, Professor of Surgery at McMaster University Medical School and Canadian Research Chair in Cardiovascular Surgery for the Population Health Research Institute, PHRI, as our Canadian Principal Investigator of the STAR-T trial, joining Dr. Michael Gibson and Dr. Michael Mack. He has an outstanding track record of trial execution and brings a superb network of Canadian clinical trial sites specializing in cardiovascular trials to the STAR-T trial. We also strengthened our cash balance with $5 million in non-dilutive debt financing from Bridge Bank, and our product gross margins recovered in the fourth quarter to 75% and are expected to reach 75 to 80 plus percent as we ramp up volume manufacturing. Last but not least, our sales momentum from the fourth quarter of last year has extended into the first quarter of this year to date with expectations of sales growth in 2023. I've left most of the clinical update to Makis to cover later on in his slides. I now have the pleasure of welcoming Irina Kulinets to our management team. Dr. Irina Kulinets joins the senior management team as Senior Vice President of Global Regulatory. Her goals are to drive U.S. and Canada regulatory strategy and execution for DrugSorb-ATR, as well as to oversee European Union MDR compliance. Irina brings 30 years of experience in regulatory affairs and clinical research with a specialty in medical devices, having a track record of success leading to regulatory approval or clearance of many medical products via Class 2 510(k) and Class 3 pre-market approval or PMA pathways in the cardiovascular and neurovascular space. Most recently, Irina served as Senior Vice President of Regulatory Affairs for MicroVention, a division of the Terumo Corporation Conglomerate that generated an estimated $0.5 billion in annual sales last year. She has also worked for major companies such as Johnson & Johnson, Boston Scientific, CynoSure, and others. And she also has extensive experience as a regulator and was appointed as a third-party FDA inspector and 510(k) reviewer on behalf of the FDA to review, assess, and approve new technology. With that, I'd like to invite Irina to have a few words. Irina?
Irina Kulinets, Senior Vice President of Global Regulatory
Thank you, Phil, for the kind introduction, and good afternoon, everyone. I'm excited to be a part of Cytosorbents team and with the current success of Cytosorbents products in many markets and encouraging trends in clinical research. I have high expectations for the patients and physician community using this product worldwide and eagerly anticipate the success of Cytosorbents products in the U.S. market. I'm looking forward to leading the registration of this lifesaving product in many important regions. This is a great opportunity to participate in the success of something so important.
Phillip Chan, CEO
Thanks so much, Irina. And now I'd like to turn it over to Kathy to discuss our financials. Kathy?
Kathleen Bloch, CFO
Thank you so much, Phil, and hello to everyone on the call today. I will be discussing fourth quarter and full year 2022 financial results including revenues and gross margins, and then I'm going to also provide an update on our working capital and our cash runway. Next slide, please. Total revenues for the fourth quarter of 2022, which include both product sales and grant revenue, were approximately $9.4 million, a 13% decrease as compared to Q4 2021 total revenue of approximately $10.8 million. Q4 2022 product sales were $7.6 million, a 21% decline over $9.7 million in Q4 2021 product sales. We note, however, that sales in Germany, our largest market, were $3.3 million in the fourth quarter of 2022, which is an increase of 33% over the prior Q3 2022 quarter. COVID-19 sales were negligible during the fourth quarter of 2022 as compared to $1.7 million in the fourth quarter of 2021. In addition, we experienced a decrease in the average exchange rate of the euro to the U.S. dollar, which lowered our fourth quarter 2022 product sales by approximately $865,000 such that on a constant currency basis, fourth quarter 2022 core non-COVID product sales were actually $8.5 million, which represents a 6.4% increase from our $8 million in core non-COVID product sales a year ago. Our grant revenue for the fourth quarter was $1.7 million compared to $1.1 million in the prior year, and our gross profit margins on product sales were 75% for the fourth quarter of 2022 compared to 78% for the prior year. The decrease that we experienced was due primarily to inefficiencies related to the relocation of our manufacturing operations to our new facility which occurred during 2022. Next slide, please. This chart breaks out our core non-COVID-19 product sales and our COVID-19 product sales by quarter. And as you can see, except for the $300,000 in COVID-19 sales in the first quarter of 2022, COVID-19 product sales have declined to virtually zero for the remainder of the year. Fourth quarter COVID-19 product sales were zero. That compares to $1.7 million in COVID-19 product sales in the fourth quarter of the prior year. Note that Q4 2022 product sales are directionally higher than the immediately prior quarter, a quarter-over-quarter increase of 18%. And I know Christian will be discussing later in the call. We are seeing positive trends in the market, particularly in Germany, our largest market. Next slide, please. Total revenue for 2022, including both product sales and grant revenue, was $34.7 million compared to $43.2 million in 2021, a decrease of 21%. Product sales were $29.4 million, representing a decline of 27% over 2021 product sales of $40.1 million. COVID-19 sales were negligible, as we said, in 2022 that compares with $6.3 million in COVID sales for the prior year. The decrease in the average exchange rate of the euro to the U.S. dollar lowered 2022 product sales by approximately $3.1 million, such that on a constant currency basis, 2022 core non-COVID product sales were $32.2 million, a 5% decrease compared to $33.8 million in core non-COVID-19 product sales one year ago. 2022 grant revenue was $5.3 million compared to 2021 grant revenue of $3.1 million. Product gross margins for the year were 70% in 2022 compared to 80% in 2021. This decrease is primarily due to the relocation, as I previously mentioned. We expect that as we increase production at our new facility during 2023, we will see gradual improvements in our gross margins, which should equal or exceed the 80% blended gross margins that we typically reported prior to 2022. Next slide, please. This chart shows our annual product sales, and it's also broken down into COVID-19 product sales, the light blue part of the bar, and core non-COVID product sales, the darker blue part of the bar, and we note that on a constant currency basis, 2022 core product sales were $32.2 million, which is just 5% lower than core non-COVID-19 product sales of $33.8 million last year. We also like to point out on this chart that core non-COVID-19 product sales are 30% higher than they were in 2019, which is the year immediately prior to the start of the pandemic. Next slide, please. Lastly, I'd just like to say a few words about our working capital and cash runway. At December 31, 2022, we had $23.8 million in cash, which includes $1.7 million of restricted cash. This also includes $5 million of loan proceeds, which we received under our debt facility in December. This is an interest-only loan over the next 12 months, and we are very comfortable with this level of debt at the moment. We are in discussions with Bridge Bank about extending our term loan commitment, which is scheduled to expire on March 24, 2023. Based on our detailed 2023 operating budget, we believe we have available cash to fund our operations beyond the next 12 months. Conservation of cash is, of course, an important corporate priority, and we are focused on controlling expenses. We have and will continue to identify potential cost-saving opportunities to reduce our cash burn. During 2022, we reduced our overall headcount by 10%. We shifted our R&D employees to solely grant-funded programs, and in addition, we've reduced our inventory levels providing for additional working capital. We have minimal capital expenditures planned for 2023 compared to $6.1 million in actual capital expenditures in 2022. Our goal is through a combination of driving an increase in sales and gross margin along with cost-cutting measures to significantly reduce our cash burn and to further extend our operating runway. While the first quarter of 2023 is not yet complete, we are observing significant reductions in our quarterly cash burn. Our spending is laser-focused and fully aligned with our strategic priorities, most notably our STAR-T clinical trial designed to support U.S. FDA marketing approval for DrugSorb-ATR. And now I've brought up clinical trials. It seems like the perfect time to turn the call over to our Chief Medical Officer, Dr. Efthymios Deliargyris. Please go ahead, Makis.
Efthymios Deliargyris, Chief Medical Officer
Thank you, Kathy, and hello to everyone on the call today. For the next few minutes, we're going to discuss primarily the progress in the STAR-T trial, also provide an update on the remaining company clinical programs and, of course, highlight some major data releases that have already happened this year. So next slide, please. So the headline for today's clinical update is that we have made solid progress and now have increased visibility as we're moving forward. The strategy that we discussed with you on the last earnings call, focusing all our resources, all our clinical resources on the STAR-T trial and expanding to Canada, I'm very happy to report that it's paying off. STAR-T is enrolling fast and has now crossed the halfway point with more than 50 patients enrolled. We can now reiterate the timelines previously stated that we will hit the next milestone of 80 patients this spring, and the trial will fully enroll this summer. The STAR-D activities remain on pause, and the plan also remains to resume this study upon completion of STAR-T. Also very encouraging is the enrollment rates with the STAR-T registry; in fact, we have enough patients enrolled that we will have the initial data readouts before the first half of this year. We're also accelerating our trials in critical care, specifically our process randomized clinical study and our COSMOS international registry, which we will focus on this year to accelerate enrollment. Finally, the positive data flow for CytoSorb will continue in 2023 with a constant stream of presentations and publications in large international conferences and peer-reviewed journals in all therapeutic areas, including critical care, liver and kidney, and cardiac surgery. Next slide, please. Now let's spend the next couple of slides talking about STAR-T. As I mentioned, we now have good visibility of the way forward. Just as a reminder, at the end of last year in December, we received a green light from the DSMB who finished their first safety review after the first 40 patients were enrolled, and recommended that we continue to study as planned without any modification. Since that time, we have experienced accelerating enrollment, and now the majority of sites participating in the trial are actively contributing. Canada came on quickly and has already contributed multiple patients to the study and is accelerating enrollment as well. Now that we are past the halfway point, we're working closely with our regulatory colleagues. And as a side note, I would like to also welcome and be very thankful for Irina joining us, such an experienced regulatory expert that will be critical in driving the filing to the FDA upon completion of the trial. As we've shown you before, on the bottom of the slide, you see the table outlining the three milestones of the trial with the first one that has already been completed that were reviewed already. The second one, which is what we should be looking for next, happening this spring, once we hit 80 patients enrolled. And then the final milestone, which represents the full enrollment of the study with 120 patients, the follow analysis of the DSMB closed out review, which we anticipate will take place this summer. Next slide, please. I want to give you a little bit more insight in the next few months as the trial is coming to completion. So let's talk a little bit about what to expect in the near future for the STAR-T trial. First, we estimate that the trial will be fully enrolled by the time the previously scheduled interim analysis process would be completed. The process that requires a soft database log with full data cleaning and full event adjudication. I'd also like to remind you that performing an interim analysis comes with a statistical price, the so-called spend of alpha. Therefore, now based on the fast enrollment, we have an opportunity to preserve all the alpha for the final analysis by forgoing the interim analysis, and we plan to do so. I will emphasize that this positive development is a direct result of the fast enrollment of the trial, which is directly related to the highly motivated investigative sites in the U.S. and Canada, and is not at all related to any safety or other known concerns. So what we should be looking for next is the enrollment of 80 patients, which, similar to what we did in late last year, will trigger a press release. From that point on, the following - the second DSMB safety review, we anticipate that the interval between enrolling the 80 patients and executing the DSMB review will likely be similar to the one from the prior review and approximately eight weeks. Next slide. Now, for the next couple of minutes, I'd like to provide you with a brief update on the progress we're making on the remaining company clinical programs. First in line, let's talk about process, a randomized clinical study in patients with refractory shock that we're executing in multiple sites in Germany. We now have the majority of those sites open and are in the process of executing an important protocol amendment that will allow earlier initiation of therapy and should also contribute to faster enrollment. This optimization of the trial was informed by observations from other studies, including our own CTC registry with its excellent results, but also from testimonials from real-world use that suggest that CytoSorb benefits are maximized with earlier initiation of therapy. This approach is also aligned with our commercialization strategy of offering treatment now to patients before they develop organ failure and require organ support, like continued renal replacement therapy with the use of a standalone hemoperfusion pump. We anticipate this amendment to be completed in the first half of the year and to drive faster enrollment in the process in 2023. Now let's turn our attention to the STAR registry. I'm happy to report that enrollment in the registry is exceeding our own projections. We believe that this is in large part driven by the increasing adoption of ATR or anti-thrombotic removal as the standard of care in many European heart centers. We already have more than 200 patients enrolled, and 2023 is an exciting year since we're going to have the initial data readouts starting with a presentation for the very large international conference of interventional cardiology EuroPCR in Paris this May. We also have submitted an additional analysis to the largest cardiovascular conference in the world, the European Society of Cardiology meeting that will take place in Amsterdam in August. Finally, we plan to present at the European Association of Cardiothoracic Surgery in Vienna next October should our submissions be accepted, of course, for these meetings. Finally, let's talk about COSMOS. This year will be the year of COSMOS. We will focus our attention and increase our resources to prioritize progress in this important registry. We believe that this platform allows enrollment for all the remaining CytoSorb applications, with the exception of antithrombotic removal across multiple therapeutic areas. The data from this COSMOS registry will generate a wealth of high-quality evidence from both the clinical benefits and the value proposition of CytoSorb for the years to come. We’re happy with the opening of the first few sites in the first two countries, Germany and Spain, and are glad to see that enrollment has shown a slight uptick in the recent months. Just as a reminder, the CTC registry, we have discussed previously in detail, the final results presented at the international European Society of Intensive Care Medicine meeting last year, and now the main results have been submitted for publication. So please be on the lookout for the formal paper to be released shortly. Next slide please. During our last earnings call, we discussed the flurry of new data in cardiac surgery that were presented at the European Association of Cardiothoracic Surgery. The study that really stood out was the multi-center analysis on staph endocarditis patients that was presented. I would like to spend a little more time now and refer you to the reference listed on the bottom for you to actually find the study online since it has now been formally published. Staphylococcus aureus endocarditis is the most serious type of endocarditis. It carries the highest risk of morbidity and carries mortality rates that can approach 40%. In this multi-center study, a total of 130 patients with confirmed staph aureus endocarditis underwent cardiac surgery and valve replacement. 75 of those patients were treated with CytoSorb, while 55 of those patients underwent surgery without CytoSorb. The main results are summarized on the slide. On the left-hand side, on the diagram you see on the bottom left the need for vasopressor support. These are drugs that are given intravenously to try to maintain blood pressure in the presence of hemodynamic instability. Patients treated with CytoSorb had a reduced need for such agents throughout the early post-operative period from right after surgery up to day three after the operation. However, what's more compelling is that the investigators specifically looked at three different mortality rates. First of all, patients who expired because of sepsis had a significantly lower rate among those treated with CytoSorb at 8% versus 22.8% in the control group. Then they looked at 90-day mortality, which was 21.3% versus 40% in the control group. This represents a significant absolute risk reduction of 18.7% in mortality, which translates to a number needed to treat to save a life of 5.3%. The authors stated that they believed these compelling benefits were largely related to the ability of the CytoSorb device to remove not only cytokines but also staphylococcal specific toxins, including staphylococcal hemolysins and toxic shock toxins. Next slide. Finally, the highlight recently that you have probably already seen in our recent press release is the fact that we are very happy to report that, for the first time, our technology has been mentioned in practice guidelines, specifically the 2023 European Society of Anaesthesiology and Intensive Care issued guidelines for the management of severe perioperative bleeding. They have included intraoperative hemoadsorption in these guidelines with a statement saying that it may be considered as an adjuvant therapy to reduce bleeding complications in patients on ticagrelor or rivaroxaban undergoing emergent cardiac or aortic surgery on CPB. Next slide, please. You will probably hear a few more words about this major development and how it's going to inform our commercialization strategy from Christian coming up next. In conclusion, we now have visibility for STAR-T with more than half of the patients enrolled, and we’re confident in the timelines of hitting the second milestone this spring and completing the trial enrollment this summer. We will proceed straight to final analysis with fully preserved alpha. There is no longer rationale for interim since the full enrollment will be complete before the interim could be executed. We anticipate that we will have top line results from STAR-T by year’s end approximately three to four months after the last patient completes the study. STAR-D remains on hold and the plan remains to restart right after we complete our operational responsibilities with STAR-T. STAR registry is ahead of schedule with anti-thrombotic removal now becoming increasingly standard of care in real-world practice. This year, we’ll prioritize both process and COSMOS with the intent of speeding up enrollment and generating critical evidence in our critical care applications. I also want to remind you that we have a fully staffed, very capable medical affairs team. The priority in Europe is to support our business in all of our therapeutic areas. We anticipate increasing adoption of our therapy in 2023 based on feedback from ongoing interactions with KOLs and users who continue to express high enthusiasm about our therapy. We believe that the constant stream of new and positive data presented at international conferences and the continuous flow of new positive publications across all of our therapeutic areas will be major tailwinds for our business and the adoption of our therapy. So thank you for your attention. And with this, I would like to turn it to Christian. Christian?
Christian Steiner, Executive Vice President of Sales and Marketing
Yes. Thank you, Makis. And good afternoon to everyone in the United States, and good evening to Europe. Kathy and Phil have already described the overall situation and the status of our business development. The macroeconomic situation has not improved and remains challenging in many ways. I want to give you a few more insights about our commercialization outside the United States and share with you what we are seeing in the markets. I do believe that we are already in the middle of stabilizing our CytoSorb commercialization. Although the environment in the markets is characterized by a shortage of personnel in hospitals, inflation, energy costs, and so on, it has not improved. But again, we have improved. Next slide, please. In the first quarter of 2022, we could further improve the number of customer visits in our direct markets. However, we are still significantly below the number we achieved before the pandemic. For example, in Germany, it's still approximately 25% lower. The shortage of personnel in ICUs leaves little time for meetings with industry representatives and for educational events. However, over the last 12 months, we could continuously increase our face-to-face time with customers. This led to the beginning of a turnaround we experienced in Q4 2022. We could stop the decline of our business and increase revenues by 16.9% compared to the quarter before. This is 15.3% higher than the comparable last quarter before the pandemic in Q4 2019. Next slide, please. A lot has been said about the impact of the pandemic on the medical device business and about a challenging new situation in healthcare systems. This chart shows on an annual basis that although we have suffered from all those circumstances and needed to absorb a 27% decline from the pandemic years, we nevertheless managed to close the first post-pandemic year 31% higher than the last pre-pandemic year. I believe that this is the last call we need to speak about the pandemic and its impacts. Although markets will not return to their previous state, we can focus on quarter-over-quarter and year-over-year growth from now on. Next slide, please. This growth will partly be driven by several phase initiatives we have reported to you in the last few earnings calls. These are ongoing and we will keep you updated regularly. A very significant growth catalyst for the next product and years will be that we are now ready to start addressing new additional customer groups and entering the mainstream market in certain indications. The chart at the lower part of the slide shows the early markets in green on the left and the big mainstream market on the right. Our draw so far has mainly come from those early market customer groups. Some of our geographic markets, like Germany, Austria, and Italy, are now mature enough to start crossing the chasm towards mainstream customers. The possible application fields for CytoSorb are numerous, and we have focused on only a few indications which are most advanced. They are the following: number one, reversal of vasoplegic shock, which includes septic shock; number two, intra- and post-operative use of CytoSorb in infected endocarditis; and number three, antithrombotic drug removal in cardiac surgery patients. The first of those three indications represents the biggest business opportunity, but it's also the most complex application as many confounding factors influence the therapy outcome. The second and third indications are part of our cardiovascular therapeutic area and represent smaller business opportunities but also promise a possibility to achieve standard of care status faster. I will give you more insights about our activities in all three therapeutic areas—cardiovascular, critical care, and liver kidney—with my next three slides. Next slide, please. The biggest development in our cardiovascular therapeutic area is that hemoadsorption therapy has made it into the new guidelines for the management of severe perioperative bleeding by the European Society of Anaesthesiology and Intensive Care, which was published on March 1 of this year. Makis has already reported on this major advancement, but I want to add two facts that are very important to us from a consolidation point and investor point of view. The authors avoided mentioning the product name CytoSorb, but only CytoSorb is specifically approved for the removal of ticagrelor and rivaroxaban, and this guideline entry is solely based on CytoSorb data and evidence. Furthermore, in this therapeutic area, several very relevant studies on CytoSorb's therapy effects in infective endocarditis patients have recently been published or submitted for publication. The body of evidence in the field is growing, and we're seeing increasing excitement and momentum in the community. The attendance at Congress symposia and educational events is rising, and we can also see that support from renowned KOLs is getting stronger. Next slide, please. In the therapeutic area of critical care, we can also report a significant step forward in the acceptance of our therapy by key opinion leaders. Although not yet in guidelines, the therapy has been integrated as a therapy option for certain patients in the consensus paper on sepsis-associated acute kidney injury by leading European nephrologists and intensivists, published just a few days ago. Additionally, several publications on the impact of CytoSorb on the underlying mechanisms of several diseases are either out or will be published within the next few weeks. This confirms and supports the medical rationale for CytoSorb's therapy. In general, we see a new openness and excitement about our therapy in the intensive care community and with KOLs. All the progress on the medical scientific side is feeding our marketing stories and argumentation lines, and I’m sure we will see an impact from this development in the coming months and quarters. Next slide, please. Last but not least, I want to discuss our third and youngest therapeutic area—liver and kidney. We have started two awareness campaigns on an international level and we see significant interest rising in these two fields: one, CytoSorb liver support in patients with liver dysfunction, and two, CytoSorb protects the kidneys from rhabdomyolysis. There is no real solution for the medical needs in these two fields, and CytoSorb has initially shown remarkable results. Inspired by those findings, there was a recent expert meeting on the topic of rhabdomyolysis at the largest German intensive care unit in Bremen, Germany. Leading nephrologists and intensivists in this field have started to reach a consensus on the use of CytoSorb in this application as well. Next slide, please. This slide illustrates how we are representing our company and the CytoSorb therapy at different medical conferences and trade shows; the two pictures in the lower part of this slide show that our symposia are attracting many attendees. Next slide, please. To summarize, we had a very challenging year in 2022 with declining business due to the impacts of the pandemic on the healthcare markets. The macroeconomic circumstances have not yet improved and will remain challenging in 2023. However, 12 months of hard work have resulted in the turnaround we saw in Q4 2022. This stabilization has continued so far in Q1 of this year, and I’m very convinced that we have just started a new phase of growth for this company. I hope I could give you some insights and a little flavor from the markets, and with that, I want to hand over to my colleague Vince Capponi, our President and Chief Operating Officer. Vince?
Vincent Capponi, President and Chief Operating Officer
Thanks, Christian. As we prepare for commercialization in the U.S. and Canada, our core sales and marketing team has established a go-to-market launch plan, identifying key personnel and sales operations to facilitate rapid entry into the market. With a total addressable market of $250 million for ticagrelor alone, we believe a blended sales model of direct and distributors will provide broad access to the market in a cost-effective manner. Our COVID-19 distributor experience in North America has aided us in identifying distributors in both Canada and the U.S. that we can leverage to supplement our direct sales effort. We believe this blended sales approach will allow broader market access and drive faster revenue growth in the early stages of launch with experienced distributors as part of the sales team. Regarding the antithrombotic removal application, we continue to receive positive feedback from our EU customers, where we see ongoing adoption and growth in the market. A device capable of meeting this unmet medical need to reduce the risk of postoperative bleeding for patients undergoing CPB has garnered positive feedback. Even among our U.S. clinical trial sites, we see enthusiasm for the development of a medical device for antithrombotic removal. If the STAR-T trial is successful, based on our experience in Europe, we believe there is significant upside ahead for our intraoperative use of DrugSorb-ATR during CPB and add-on applications related to hospital-wide use as a pre-operative treatment, which is a subject for future label expansions. Reimbursement is a key consideration when launching a new medical product. We believe DrugSorb-ATR would likely fall under the TCET or Transitional Coverage for Emerging Technologies reimbursement program for breakthrough devices under CMS. A favorable program announcement from CMS is expected in late April, which would strengthen the value proposition for DrugSorb-ATR, especially in the elderly Medicare population, a major demographic we will address. However, given the value proposition, we believe DrugSorb-ATR presents the TCET would be helpful, but not necessary for us to be successful in the market, in our opinion. In summary, as we finalize our commercial launch plans, our core commercial team is working closely with our clinical team to gain customer insights. Additionally, as we look to commercialization, we are working closely with our regulatory team, aligning our commercial operations build-out with our regulatory filing. Next slide, please. Regarding the new facility, the end of 2022 marked a significant milestone for the company with the successful transfer of polymer manufacturing to the new facility and complete integration of the company under one roof. The polymer plant is fully commissioned and producing polymer today, supplying our device manufacturing lines. An early look at KPIs suggests we should continue to see improvements in efficiency as a result of consolidating the operation under one roof and in a contiguous manufacturing space and scale. We’re currently ramping production to replace inventories that we utilized to bridge the transfer of operations, and we look forward to continued improvements in efficiency as we gain experience running the new plant. Moving now to the cost of goods: the 2022 gross margins dipped to 70%, driven by the two plant shutdowns associated with the transfer of operations and several other non-recurring items. We expect to see increases in gross margin to historical levels of 80-plus percent as the year progresses in hand with increased sales as we experience a recovery in our core business. Next slide, please. Our R&D and product development teams are focused on two key areas: HemoDefend-BGA and DrugSorb-ATR. The HemoDefend market opportunity is large, covering three market segments encompassing military, civilian, and plasma processing industries. Our initial entry into the market will be focused on military applications associated with universal plasma fresh whole blood and freeze-dried plasma applications. Follow-on commercialization efforts will address the larger civilian market encompassing blood transfusions and the plasma processing industry. We continue to receive strong government funding for our research programs. In 2022, we received an additional $6.1 million in grant funding for our HemoDefend-BGA product and Phase 1 grant for CytoSorb-XL to address endotoxin removal. The backlog of grant funding currently stands at approximately $11.5 million, and it’s important to note that this funding is non-dilutive, providing a cost-effective vehicle to advance the CytoSorb polymer platform. Product development continues to drive the DrugSorb technical manufacturing plan, finalizing packaging and validation of DrugSorb-ATR in our new facility. This work, in conjunction with our clinical trial data, will support our future regulatory submission and the launch of DrugSorb-ATR in the U.S. and Canada. In conclusion, the R&D team remains focused on advancing these programs to support the development and monetization of these assets.
Phillip Chan, CEO
Thank you very much, Vince. Our earnings released today covers much of this in greater detail. But just to give you some expectations for 2023. First of all, as you’ve heard today, we expect completion of the STAR-T pivotal trial in the U.S. and Canada this year with regulatory submission to the FDA and Health Canada to follow. We have increased visibility on the likelihood now of DrugSorb-ATR contributing to future sales should the STAR-T trial be positive. We expect a rebound in international sales growth this year with economic relief for hospitals expected throughout Europe. We have many new initiatives to drive sales growth, including new clinical data. We are now conducting full CytoSorb production from our new Princeton manufacturing facility with an expectation of a restoration of product gross margins to the 75% to 80%-plus range that we have historically achieved. We have been able to achieve this through historically. We also expect more normalized year-over-year comparisons now that we believe that the euro has bottomed in 2022 and the fact that we did not have any COVID-related revenue, or nominal COVID-related revenue in 2022. Lastly, we expect to have reduced cash burn with tight control over expenses, with no major capital expenditures, with our current cash balance expected to be more than sufficient to drive our 2023 operating plan. With that, that concludes our current prepared remarks. Operator, please open the call up for the Q&A session.
Operator, Operator
Thank you. Our first question comes from Mike Sarcone with Jefferies. Please go ahead.
Mike Sarcone, Analyst
Hey, good afternoon, and thanks for taking my questions.
Phillip Chan, CEO
Hey, Mike.
Mike Sarcone, Analyst
So my first one, just, as it relates to STAR-T, can you maybe talk to us about how you’re thinking about approval, timelines, post submission and top line data presentation?
Phillip Chan, CEO
Yes, thank you. Thanks, Mike. Makis and Irina, would you like to comment on that?
Efthymios Deliargyris, Chief Medical Officer
Sure, Phil.
Irina Kulinets, Senior Vice President of Global Regulatory
Yes. Thank you, Phil. I can comment on that. At the moment, we’re developing our regulatory strategy and would be able to inform the investment community when the regulatory strategy would be finalized. We’re still waiting for results of the clinical study and we’ll be acting exactly upon receiving the favorable results.
Mike Sarcone, Analyst
Okay, thank you. And just my second question you’ve talked about a continued focus on reducing OpEx and you’ve made some progress so far. Can you just elaborate, are there any areas for incremental improvement that you could streamline even further?
Phillip Chan, CEO
Kathy, did you want to take that?
Kathleen Bloch, CFO
Sure, Phil. I can take that. We’re constantly looking at making sure that we’re focused on our core initiatives. We do this in waves, right? You do one pass, and then another pass, and then another pass. One of the things that we did, as Mike has talked about earlier, was we paused our STAR-D trial. So we saved an estimated $4 million in costs in 2023 by just putting that trial on pause. We’re always looking for opportunities, and as we review our budget versus actual, we identify non-essential items. Not having capital expenditures this year will save us $6.1 million. We’re open to other opportunities as we review our operating results and our budget versus actual comparisons. You’ll see dramatic reductions in the burn this year. Really dramatic.
Mike Sarcone, Analyst
Okay, great. Thank you.
Phillip Chan, CEO
Thanks, Mike.
Operator, Operator
Our next question comes from Josh Jennings with TD Cowen. Please go ahead.
Josh Jennings, Analyst
Hi, good afternoon. Thanks for taking the questions. Phil, it was great to see you earlier this week, and congratulations again on the guideline announcement. I was hoping to just ask first on the guidelines. I think there will be some STAR registry readouts throughout this year. How should we think about the commercial adoption ramp for DrugSorb-ATR in the second half of 2023 or maybe throughout 2023? Are these big catalysts, or is the STAR-T trial really going to be the big driver of adoption? Not only approval but adoption in the United States and internationally?
Phillip Chan, CEO
Thanks, Josh. Micus, did you want to take that question?
Efthymios Deliargyris, Chief Medical Officer
Sure. Let me just, first of all, the guidelines you heard from multiple people on the call today. We see that as a major development. Getting into the guidelines is a milestone for any therapy, any drug, any device. So we think that’s definitely a tailwind. It gives a different stature to the therapy and, of course, gives the credibility from the review of tens of experts who formed this guideline committee. So there’s no question; I think that’s a positive. The STAR registry will have serial data readouts. We’re hoping this year, as I mentioned, one presentation is already locked in this May in Paris in a massive meeting, the EuroPCR meeting. But we think we’re going to have more. The reason we’re going to have sequential analysis is because we’re seeing robust enrollment—the numbers keep rising, and therefore statistical power increases, allowing us to look at subgroups, different drugs, different types of patients, different types of surgery. We think the body of evidence will continue to grow and will support what we’re already seeing, which is an increasing adoption and increasingly as standard of care in many heart centers. The STAR-T trial will open up the U.S. and North American market, U.S. and Canada, hopefully, if positive, of course. Once that’s in play, we think then the story around ATR will be complete in addition to some health economic analysis that have already begun to make their way from different healthcare systems showing that there’s a lot of cost savings associated with that procedure.
Josh Jennings, Analyst
Definitely. Thanks for that download. Wanted to ask about the gross margin expansion and the return to that 75% to 80% range on product gross margins. Is there any way to break out just the reliance on that expansion to volume growth versus some of the cost reduction issues or recovery in costs? And also just on top of that, are there any pricing dynamics for CytoSorb that we should understand?
Phillip Chan, CEO
Vince, do you want to take the first part of that, or Kathy?
Vincent Capponi, President and Chief Operating Officer
Sure.
Phillip Chan, CEO
And then Christian, maybe you can talk about the pricing stability. Thanks.
Vincent Capponi, President and Chief Operating Officer
Okay. Sure. I’ll take the first part about the gross margin. There have been efficiencies associated with this new facility, and there will also be reductions in costs just from efficiencies because we’re under one roof as opposed to the two sites we were in previously. But the second thing is the volume in the business is starting to come back. The fact that we’ve scaled so much now, the overhead absorption will be much better as we drive more volume out of here. Continued gross margin reduction will be a factor of both obviously improvements in efficiency because of the new location and increases in demand from the market, and that will continue to drive the price. As with most businesses that are volume-driven, the higher the volume, it drops relatively quickly with increasing volume.
Christian Steiner, Executive Vice President of Sales and Marketing
Thank you, Josh, for the question. I have to say the price stability for CytoSorb is very high. We have stable customer prices and even saw slight price increases in different markets. This is mainly backed by a continuous expansion of the therapy's value. As you have heard from Makis, there’s a constant stream of new clinical data supporting the price and enhancing the value proposition. I think we are not yet finished with this development and can present, in the next two quarters and years, an increased body of evidence and much more support for the therapy. So very stable pricing, I have to say, all over the world.
Josh Jennings, Analyst
Great, thanks. Maybe just one last question. Phil, we’re going to just hear—sometimes it’s hard for us to track some of these international markets, but how is the competitive landscape for heme purification technology shaping up? Anything we should have on our radar? Thanks so much.
Phillip Chan, CEO
Hi, Josh. Thanks for the questions. I think that from a competitive standpoint, you can look at the level of competitiveness of our technology based on others just by looking at the volume of publications that have been put out by users over the years. We have some Chinese competitors that are trying to break into the acute care marketplace. But if you do a search on their technology, or if you search for really our major competitor, which is Baxter and their offerings, you can see that the volume of those publications is very low compared to the amount of time they’ve been in the marketplace compared to our published list, which continues to grow significantly each year to, again, hundreds of published articles now. I think that we are continuing to remain the leader in the blood purification space to treat life-threatening inflammation and acute care diseases. We are the leader in fact, the only player approved specifically to reduce anti-thrombotic agents in the European Union under our CE marks certificate and continue to drive that leadership through new innovation and some of the studies you’ve seen in staph aureus endocarditis and acute respiratory distress syndrome and in liver treatment of acute liver disease and many others.
Josh Jennings, Analyst
Excellent. Thanks, Phil.
Operator, Operator
The next question comes from Sean Lee with H.C. Wainwright. Please go ahead.
Sean Lee, Analyst
Good afternoon guys, and thanks for taking my questions. My first question is previously you mentioned that the revenue reduction in 2022 was mostly due to several headwinds, including the prevalence of mild COVID cases that limited access to hospitals. So I was wondering, have those headwinds cleared up so far this year, and what’s your outlook for 2023?
Phillip Chan, CEO
Yes, thanks, Sean. Maybe Christian, you can comment on that, and if I needed, I can comment as well.
Christian Steiner, Executive Vice President of Sales and Marketing
Yes, thank you very much for the question. Yes, I think the situation is very complex including the pandemic and after the pandemic. While we had, in the beginning of the pandemic, a lot of treatments of COVID patients and our sales and revenues surged. When vaccination became available for the disease and also the virus changed, we had much more manageable cases and not so many ICU patients from COVID, leading to fewer COVID patients needing treatment. On the other hand, during the pandemic, a lot of impacts were felt in healthcare systems. In the beginning, many ICUs were blocked for COVID patients so that other patients could not even enter the ICU. As a result, many surgeries were postponed or even canceled. This has led to numerous deaths of patients who could not be operated on or treated. So this together with the COVID pandemic, which led to the loss of many people, particularly among the elderly population, has created a situation in 2022 with fewer patients on the ICUs. While personnel shortages in ICUs persist, patient volumes are slowly rebounding; this is mainly because surgery programs have ramped up again and are not yet at full speed but are much better than at the beginning of 2022. I think this underscores the ongoing situation regarding ICU patients and cardiac surgeries. Phil, any additions?
Phillip Chan, CEO
Yes, I think as Christian mentioned, the further we— I think the FDA will actually call into the pandemic soon given that the rates of COVID are very low around the world. The impact that COVID will have on our markets will sequentially decline. Certain issues that we face in the market today in terms of staffing shortages remain worldwide, particularly in nursing. However, I think gradually those things will improve. One of the major issues I mentioned in my remarks that really hurt was the drop in the euro. The weakness in the euro— since the majority of our revenue is based in euros— this drop in the euro caused a significant drop in our revenue base in dollars. I believe the euro has likely bottomed as of last year. It is still near parity with the U.S. dollar, but predictions indicate that the euro will remain stronger than the dollar. Thus, year-over-year comparisons should appear better. I look forward to avoiding discussion of this every quarter. Other indicators are improving as well. It has been helpful that our stock prices improved, opening opportunities for us to gain new investors and other benefits. So thank you.
Sean Lee, Analyst
Great. Thank you. My second question is on the endocarditis study. The results are certainly encouraging. I was wondering whether a similarly designed prospective study could be used to support U.S. approval in that indication?
Phillip Chan, CEO
Makis, do you want to take that question?
Efthymios Deliargyris, Chief Medical Officer
Sure. Yes, endocarditis is an exciting area. Last year we hired our Vice President of Medical Cardiovascular, Dr. Daniel Wendt, who was a distinguished cardiac surgeon for many years and kept telling us about the clear benefits that you saw and how well these patients were doing when treated with CytoSorb endocarditis patients. We’re seeing again, data coming out from multiple centers suggesting that managing hyper-inflammation, controlling hemodynamics, is very important for the outcomes of these patients. Absolutely, there’s a possibility for us to design and execute a prospective study. However, what you’ve heard from the last earnings, and you’re hearing again from us, is that there’s also a need and desire to stay focused and execute the task at hand. So with STAR-T and STAR-D already determined as being our next two studies, I think an endocarditis study would fit very nicely down the road since we will be working with the same institutions, the same physicians, the same investigators. With the accumulating data, we could identify the right population for the study. So focus on antithrombotic removal for the near term, but certainly considering endocarditis as an opportunity in the midterm.
Sean Lee, Analyst
I appreciate your thoughts. Thanks. That’s all I have.
Phillip Chan, CEO
Thanks, Sean.
Operator, Operator
Next question comes from Tom Kerr with Zacks Investment Research. Please go ahead.
Tom Kerr, Analyst
Hi guys. Most of my questions have been asked and answered. Just two quick financial ones. Can you refresh my memory on the grant income backlog? Is that received over one year? Does that get spread out over two to three years? I forget.
Phillip Chan, CEO
Yes, the grant backlog is $11.5 million, and it’s typically spread out over multiple years. These contracts with the DoD and other agencies are typically multi-year contracts where those dollars are earned over the course of the contract.
Tom Kerr, Analyst
Okay. But we don’t know if this is a two or three-year contract or related to timeframe?
Phillip Chan, CEO
It’s a compilation of many different grants in fact. Many of those grants, particularly the ones we received last year, still have a two to three year timeframe on them. But it varies. Some are nearing completion, but some are just beginning.
Tom Kerr, Analyst
Got it. Okay. And then just the last question is on the capital expenditures. As I understand it’s going to be diminished this year. But does that have to get ramped back up over the next three to five years? Would it ever get back in the millions or can you operate this business at very, very low CapEx needs?
Phillip Chan, CEO
Kathy, did you want to talk about that and maybe touch on the commercial expansion as well as if Drugs.
Kathleen Bloch, CFO
Yes, I think that with our CapEx of $6 million last year, that was because of the opening of our new manufacturing facility. That was a big bulge of expense that we won’t be experiencing hopefully for another 10 years or so. But our capacity has grown fourfold from 80 million to now 350 million to 400 million in annual capacity. So we should be pretty well set at our current plant. Prior to opening the new plant, our CapEx spend was generally $300,000 to $500,000 a year. Now that we have all new equipment in our facility, we have new labs, we can expect that maintenance capital needs will be low as we move forward, I would say over the next five years at a minimum.
Tom Kerr, Analyst
Okay. All right. That’s all I have. Thank you.
Phillip Chan, CEO
Thanks, Tom.
Operator, Operator
And at this time, I would like to turn the call back to management for any additional or closing remarks.
Phillip Chan, CEO
Well, thank you very much, everyone, for taking the time to get on this call with us and get an update on Cytosorbents’ progress. We’re very excited about the near-term future, particularly with the pending completion of the STAR-T pivotal trial. If you have any questions that were not answered today, please feel free to reach out to Kathy at [email protected], and we’ll try to get you those answers as soon as we can. Thank you, everyone, and have a good night.
Operator, Operator
Thank you. That concludes our conference for today. I’d like to thank everyone for their participation and have a great day.