A Prospective, Multicenter, Randomized trial to Assess Efficacy and Safety of the CERA Occluder in Congenital Heart Disease (ASD/VSD/PDA): CERA TRIAL Zhi-wei Zhang MD On Behalf Of Cera Trail Investigators Professor Of Guangdong General Hospital

Background Heartr occluder Cera occluder HeartrTM occluder is a self-expandable, double disc device made from a Nitinol wire mesh. CeraTM occluder (ASD, VSD, PDA) developed from the prior generation occluder (ASD, VSD, PDA)- HeartrTM occluder. In order to decrease the dissolution of nickel ion, the surface of nitinol wire was covered with TiN membrane

Background Cera occluder Heartr occluder The results of animals showed that the CERA occluder reduce inflammation and thrombus, promote the endothelial cells growth

Objective To Establish The Safety And Effectiveness Of Cera TM Occluder (ASD/ VSD/ PDA) Compared With HeartrTMOccluder In A Multicenter, Randomized Clinical Trial .

Study design CeraTM Occluder n=232 (ASD/VSD/PDA) Randomized, Open Label, Active Control, Parallel Assignment, Safety/Efficacy Study 464 patients at 11 centers CeraTM Occluder n=232 (ASD/VSD/PDA) Heartr TM occluder n=232 (ASD/VSD/PDA) Clinical follow-up (ECHO/ ECG /X-RAY) 30 d 3 mo 6 mo 11 Sites In China

Major inclusion and exclusion criteria (ASD) Echocardiographic evidence of ostium secundum atrial septal defect Age ≥2 years and ≤ 65 years The maximum stretch diameter of the defect shorter than 40 mm, and total length of the atrial septal longer than the device The margins of the defect are larger than 5mm to the coronary sinus, AV valves or right upper lobe pulmonary vein. The ostium primum ASD or coronary sinus ASD Severe pulmonary hypertension and right to left shunt Severe myocardial diseases or valve diseases independent with ASD Thrombus in cardiac cavity or vein absolutely closured by lower limb venous thrombosis

Major inclusion and exclusion criteria (VSD) Echocardiographic evidence of Ventricular Septum Defect (VSD) age ≥3 years and ≤65 years. diameter of left ventricular ranged at 3-14 mm (children < 10 mm). if the right perimembrane VSD is multiple, one of these holes should larger than 2 mm at least the margins of the defect are larger than 2 mm to the aortic valve without observed aortic valve prolapsed and reflux Left to right shunt of ventricular shunt in main Aortic valve prolapsed, aortic insufficiency, or have a poor anatomy position of the VSD where interfere the function of aortic valve or atrioventricular valve Severe pulmonary hypertension and right to left shunt Absolutely closured by lower limb venous thrombosis

Major inclusion and exclusion criteria (PDA) Echocardiographic evidence of patent ductus arteriosus defect (PDA) Single PDA, or have PDA and other slight cardiovascular abnormalities without surgery therapy Age ≥4 months, ≤65 years Weight ≥6 kg The minimum diameter of the PDA ranged at 2-16 mm Other cardiac anomalies should corrected by surgery therapy, or cardiac anomaly depend on the presence of PDA Severe pulmonary hypertension and right to left shunt

Study Endpoint Primary Study Endpoint Secondary Study Endpoint Procedure success through 6 months post-randomization Secondary Study Endpoint Adverse events (AEs) directly related to the device, procedure in 6 months

Outcome definitions Procedure success: Adverse events (aes) Position of the occluder is proper by TTE/TEE observing, and with litter or without residual shunt and without observed atrioventricular valve reflux. Adverse events (aes) Hemolysis: any drop in haemoglobin (hb) of >2.5 g/dl within 24 hours Severe acute haemolysis: hb ≤5 g/dl or received blood transfusion according to clinical judgement of study physician. Thromboembolism: thrombosis that required thrombolytic therapy Migration or shedding of the occlude: required surgical removal of the device

Follow up Clinical and chest x-ray, ECG, echocardiogram follow 1, 3, 6 months post-randomization

CERA Trial – participants “11 centers in china” Investigator HOSPITAL N 1 Zhang zhiwei Guangdong General Hospital, 136 2 Zhou shenghua Second Xiangya Hospital, Central South University, 84 3 Zhou daxin Zhongshan Hospital Fudan University, 40 4 Pu xiaoqun Xiangya Hospital Central-south University 5 Yu bo The 2nd Affiliated Hospital Of Harbin Medical University 6 Ma chunye The First Hospital Of Jilin University 36 7 Dai zhengxue Xijing Hospital, The Fourth Military Medical University,, 32 8 Li shumei The Second Hospital Of Jilin University , 20 9 Chen lianglong Fujian Medical University Union Hospital 10 Hua yimin West China Second University Hospital 11 Wu feifeng The First Affiliated Hospital Of Guangxi Medical University,

Sample size calculation and statistical analysis Statistical assumptions One-sided 95% upper confidence bound for the difference in means between groups Margin of difference to support non-inferiority was 0.10 Alpha=0.05, Power=80% A sample size of 464 patients(232 patients per groups ) was calculated All enrolled patients were included in the analyses of primary and secondary outcomes according to the intention-to-treat principle

Clinical trial organization Principal Investigators: Zhiwei Zhang , MD Guangdong General Hospital Clinical Events Committee Bo Yu, MD The 2nd Affiliated Hospital Of Harbin Medical University Data Safety Monitoring Board: Shenghua Zhou, MD Second Xiangya Hospital, Central South University, Data Management : Hao Yu , PHD Nanjing Medical University

Patient population CERA HEARTR P-VALUE Total Patients Enrolled 232 Intent To Treat 1 3 Anatomical Condition 2 Shunt Minor Total Attempted Patients 231 229

patients demographics CERA(n=231) HEARTR (n=229) P-VALUE Age (years) TOTAL 19.7±17.0 (0.4～68.0) 20.8±17.0 (0.2～61.0) 0.31 ASD 28.9±15.8 31.8±15.8 0.25 VSD 12.6±12.5 13.2±11.8 0.41 PDA 17.6±18.1 17.2±16.9 0.82 <20years% 131(56.71%) 133(58.08%) 0.77 22(28.21%) 20(25.97%) 0.75 62(80.52%) 59(77.63%) 0.66 47(61.84%) 54(71.05%) 0.23 Gender male(%) 79(34.20%) 74(32.31%) 0.67 26(33.33%) 19(24.68%) 0.24 36(46.75%) 38(50.00%) 0.69 17(22.37%) NS

patients demographics CERA (n=231) HEARTR(n=229) Weight (kg) TOTAL 37.2±20.5 (6.5～90.0) 40.2±19.9 (6.0～90.0) 0.12 ASD 47.9±16.6 52.8±14.6 0.06 VSD 31.0±19.9 32.2±19.0 0.42 PDA 32.1±20.6 35.2±19.5 0.34 Height (cm) 133.4±33.2(46.0～187.0) 136.7±30.3 (60.0～185.0) 0.48 150.5±23.1 156.4±17.4 0.30 127.0±29.1 125.7±25.5 0.82 121.5±38.5 126.4±34.7 0.40 Heart Murmur(%) 194 (84.0%) 195 (85.2%) 0.73 62 (79.5%) 57 (74.0%) 71 (92.2%) 70 (92.1%) NS 61 (80.3%) 68 (89.5%) 0.11

Baseline medical data CERA HEARTR P-VALUE n=231 n=229 CHF 13(5.63%) 18(7.86%) 0.34 Failure To Thrive 2(0.87%) NS CAD 4(1.75%) 0.21 Diabetes Embolization 1(0.43%) 0.62 Stroke Hypertension 9(3.90%) 9(3.93%) Syncope 3(1.30%) 0(0.00%) 0.25 Chest Ache 4(1.73%) 7(3.06%) 0.38 Major Complications: Events that are life threatening, prolong hospitalization or have long-term consequences or need for ongoing therapy. These include but are not limited to cerebral embolism, cardiac perforation with tamponade, endocarditis, pericardial effusion with tamponade, repeat surgery, death, cardiac arrhythmias requiring permanent pacemaker placement or long term anti-arrhythmic medication and device embolizations requiring immediate surgical removal. Minor Complications: Device embolization with percutaneous retrieval, cardiac arrhythmia with treatment, phrenic nerve injury, hematoma, other vascular access site complications, retroperitoneal hematoma, surgical wound complications, other procedural complications, pericardial effusion requiring medical management, evidence of device associated thrombus formation without embolization (with or without treatment) and marker band embolization without known sequelae.

Baseline echocardiographic characteristics CERA HEARTR P-VALUE ASD N=78 N=77 Defect size (mm) 16.8±6.2 (6.0～30.0 ) 19.5±6.2 (5.5～35.0) 0.01 LVEED 38.6±6.6 39.025±6.025 0.71 RVD 34.8±11.7 36.499±12.149 0.42 RAD 40.4±9.4 42.300±10.993 0.33 LVEF 66.6±5.6 66.520±6.940 0.84 VSD N=76 6.0±2.6 (2.0-13.0) 5.8±2.5 (2.3-14.0) 0.64 LV 39.3±7.5 40.5±7.7 0.34 LAD 26.8±6.6 27.2±6.7 0.92 66.6±6.1 68.7±7.9 0.09 PDA 5.5±2.2 (2.1～10.4) 5.9±2.8 (2.6～16.0 ) 0.58 46.6±12.1 48.4±12.4 0.53 29.9±8.4 31.5±8.2 0.24 EF 65.5±7.2 65.7±8.0 0.93

Baseline characteristics CERA HEARTR P-VALUE Qp/QS ASD (CERA N=48, HEARTR N=47) 2.24±0.88 2.62±1.66 0.49 VSD (CERA N=59, HEARTR N=56) 1.53±0.84 1.53±0.54 0.38 PDA (CERA N=31, HEARTR N=35) 4.31±6.11 3.31±4.19 0.70 PAP(M) ASD (CERA N=63, HEARTR N=62) 20.13±8.38 19.60±5.25 0.88 VSD (CERA N=65, HEARTR N=64) 16.09±5.68 17.39±6.34 0.29 PDA (CERA N=64, HEARTR N=62) 25.25±13.49 25.66±13.97 0.93 PAP/AP ASD (CERA N=57, HEARTR N=55) 0.27±0.10 0.26±0.07 0.83 VSD (CERA N=56, HEARTR N=57) 0.24±0.07 0.25±0.07 0.56 PDA (CERA N=63, HEARTR N=59) 0.35±0.15 0.33±0.15 0.39 Major Complications: Events that are life threatening, prolong hospitalization or have long-term consequences or need for ongoing therapy. These include but are not limited to cerebral embolism, cardiac perforation with tamponade, endocarditis, pericardial effusion with tamponade, repeat surgery, death, cardiac arrhythmias requiring permanent pacemaker placement or long term anti-arrhythmic medication and device embolizations requiring immediate surgical removal. Minor Complications: Device embolization with percutaneous retrieval, cardiac arrhythmia with treatment, phrenic nerve injury, hematoma, other vascular access site complications, retroperitoneal hematoma, surgical wound complications, other procedural complications, pericardial effusion requiring medical management, evidence of device associated thrombus formation without embolization (with or without treatment) and marker band embolization without known sequelae.

Clinical utility results CERA HEARTR P-VALUE ASD Procedure time (min) 58.2±33.5 58.0±25.5 0.86 Range (min) 20.0～270.0 20.0～130.0 Occluder waist size (mm) 24.2±7.8 27.3±8.5 0.02 Range (mm) 10.0～40.0 10.0～42.0 VSD 74.5±30.4 77.5±28.4 0.47 20.0～180.0 30.0～155.0 7.8±2.9 8.0±2.6 0.25 4.0～18.0 PDA 59.8±19.3 53.5±21.7 0.03 25.0～120.0 9.0±3.0 9.3±4.5 0.79 4.0～14.0 4.0～26.0

Technical and procedure success CERA HEARTR P-VALUE Technical Success 228/231(98.70%) 227/229 (99.13%) NS ASD 76/78 (97.44%) 77/77 (100.00%) 0.50 VSD 76/77 (98.70%) 74/76 (97.37%) 0.62 PDA 76/76 (100.00%) procedure success 226/228(99.12%) 225/227(99.12%) 1.0000 75/76 (98.68%) 73/74 (98.65%) Major Complications: Events that are life threatening, prolong hospitalization or have long-term consequences or need for ongoing therapy. These include but are not limited to cerebral embolism, cardiac perforation with tamponade, endocarditis, pericardial effusion with tamponade, repeat surgery, death, cardiac arrhythmias requiring permanent pacemaker placement or long term anti-arrhythmic medication and device embolizations requiring immediate surgical removal. Minor Complications: Device embolization with percutaneous retrieval, cardiac arrhythmia with treatment, phrenic nerve injury, hematoma, other vascular access site complications, retroperitoneal hematoma, surgical wound complications, other procedural complications, pericardial effusion requiring medical management, evidence of device associated thrombus formation without embolization (with or without treatment) and marker band embolization without known sequelae. Technical Success: successful deployment of the device, Patients who received the device procedure who had successful closure of the defect(≤2.0mm residual shunt )

Closure success CERA HEARTR P-VALUE 1MONTH 220/224 (98.21%) TATOL 220/224 (98.21%) 217/224 (96.88%) 0.54 ASD 71/74 (95.95%) 72/75 (96.00%) NS VSD 73/74 (98.65%) 69/73 (94.52%) 0.21 PDA 76/76(100.00%) 3 MONTH 211/216 (97.69%) 210/217 (96.77%) 0.56 68/71 (95.77%) 70/74 (94.59%) 71/72 (98.61%) 0.37 72/73 (98.63%) 72/72 (100.00%) 6MONTH 222/224 (99.11%) 213/218 (97.71%) 0.28 74/76 (97.37%) 77/77 (100.00%) 0.05 71/71 (100.00%) Major Complications: Events that are life threatening, prolong hospitalization or have long-term consequences or need for ongoing therapy. These include but are not limited to cerebral embolism, cardiac perforation with tamponade, endocarditis, pericardial effusion with tamponade, repeat surgery, death, cardiac arrhythmias requiring permanent pacemaker placement or long term anti-arrhythmic medication and device embolizations requiring immediate surgical removal. Minor Complications: Device embolization with percutaneous retrieval, cardiac arrhythmia with treatment, phrenic nerve injury, hematoma, other vascular access site complications, retroperitoneal hematoma, surgical wound complications, other procedural complications, pericardial effusion requiring medical management, evidence of device associated thrombus formation without embolization (with or without treatment) and marker band embolization without known sequelae. Closure success :among patients that were technical successes, closure of the defect (ASD/VSD/PDA defined as a shunt ≤2mm) without the need for surgical repair significant

Nickel serum concentrations —paediatric patients in Guangdong General Hospital Time CERA (ng/ml) HEARTR (ng/ml) P-VALUE Before 0.827±0.665（n=46） 0.586±0.518 （n=47） 0.054 24-hours 0.654±0.444 （n=45） 0.974±0.512 （n=45） ﹡ 0.002 1 month 0.937±0.495 （n=45） 1.982±0.694（n=40） ﹡﹟ 0.000 3 months 0.824±0.468 （n=39） 1.401±0.918 （n=42）﹡﹟ 0.001 6 months 0.486±0.176（n=43） 0.617±0.421 （n=43）☆＆ 0.065

Nickel serum concentrations The rise in the mean serum levels of nickel 24 hours and 1 and 3 months after implantation was significant in the control group (P<0.005), but no significant difference in the CERA group. There was no significant difference in the mean serum levels of nickel before implantation and 6 months after the procedure （P>0.5）. The mean serum levels of nickel are significant higher of the control group than the CERA group at 24 hours and 1 and 3 months after implantation (P<0.005).

Nickel serum concentrations 6 month 3 month 1 month 24 hours Before 2.10 1.80 1.50 1.20 0.90 0.60 0.30 Nickel concentration (ng/ml） B A CERA B HEARTR

Results cera heartr Major complications Cardiac Arrhythmia Requiring Major Treatment Death (Device Or Procedure ) Device Embolization with percutaneous removal device Embolization With Surgical Removal Pericardial Effusion with tamponade Device Dislocation With Surgical Removal 1

Results minor complications cera heartr P-VALUE Anemia Allergic Reaction (Drug) Cardiac Arrhythmia Minor Treatment 16(6.93) 25(10.92) 0.13 ASD 2(2.56) 5(6.49) 0.28 VSD 11(14.29) 19(25.00) 0.10 PDA 3(3.95) 1(1.32) 0.62 Thrombus Formation Upper Respiratory Infection 2 Headaches/Possible TIA Pericardial Effusion Pseudoaneurysm Puncture Site Hematoma Venous Thrombosis 1

Conclusion animal experiments and in vitro experiments both show that ceramic membrane occluder can restrain the thrombosis and promote the growth of endothelial tissue. This trial show the ceramic occluder occluder (CERATM) have the same clinical safety and effectiveness, compare with the general Nitinol occluder (heartrTM ).

Conclusion according to this clinical trail , there is no statistical significance between the CERA group and HEARTR group . But we believe that for this difference was not significant due mainly to the design of this study and test methodology, may need a larger sample size and longer observation time to identify the Obvious advantage of the ceramic membrane occluder relative to the normal occluder .

Thanks