1. The DEFLECT III Trial:
A Prospective Randomized Evaluation of the TriGuard Embolic DEFLECTion Device during Transcatheter Aortic Valve Replacement
Alexandra Lansky, MD
Yale University School of Medicine
New Haven, CT
Joachim Schofer, Szilard Voros, Adam Brickman, Didier Tchetche, Pieter Stella, Jochen Reinöhl Thomas Cuisset, Daniel Blackman, Michael Cleman, John Forrest, Gil Bolotin, Med Spitzer, Martine Gilard, Thomas Modie, David Hildick-Smith,
Kevin Abrams, Michael Haude, and Andreas Baumbach

2. Disclosure Statement of Financial Interest
Affiliation Financial Relationship
Research grants:
Consultant/Speaker Honoraria:
Minor Ownership interest:
Company
Keystone Heart, Bard, Biotronik, Boston Scientific, CardioKinetix, Direct Flow, Gilead Sciences, Gore, Intact Vascular, Micell, Recor Medical, Shockwave Medical, SilkRoad Medical, St Jude Medical, TriReme Medical, Ventrix Medical, Veryan Medical
AstraZeneca Pharmaceuticals, Eli Lilly and Company, Daichi Sankyo, CardioDX, Merk & Co.
Keystone Heart

3. Clinical Stroke after TAVR
30-day stroke rates
4-7% at 30 days in RCTs
Generally under-reported (17% after SAVR when evaluated by neurologist)
Confer 3- to 9-fold increased risk of mortality
50% are peri-procedural
Stroke is the most devastating complication following TAVI. For many patients the fear of stroke is greater than the fear of mortality
Leon et al. NEJM. 2010;363:1597, Smith et al. NEJM. 2011;364:2187, Adams et al. NEJM 2014;370:1790, Leon MB ACC 2013, Popma et al. JACC 2014;63:1872, Eggebrecht et al. EuroIntervention. 2012;8:129, Messe et al. Circulation 2014;129:2253, Tchetche et al. JACC Cardiovasc Interv 2014;7:1138, Miller et al. J Thorac Cardiovasc Surg 2012;143:832

4. Silent Embolic Events on DW-MRI after TAVR
% of Subjects with New Lesions
Affect % of patients
Multiple infarcts (≤36, x̅ = 4.6)
Associated with:
Neurocognitive decline
>2 fold risk of dementia
>3 fold risk of stroke
Stroke is the most devastating complication following TAVI. For many patients the fear of stroke is greater than the fear of mortality
Restrepo et al. Stroke 2002;33:2909, Lund et al. Eur Heart J. 2005;26:1269, Schwarz et al. Am Heart J 2011;162:756, Knipp et al. Ann Thorac Surg 2008;85:872, Vermeer et al. NEJM 2003; 348:1215, Vermeer et al. Stroke 2003; 34:1126, Arnold et al. JACC Cardiovasc Interv. 2010;3:1126, Astarci et al. J Heart Valve Dis. 2013;22:79, Fairbairn et al. Heart 2012;98:18, Ghanem et al. EuroIntervention. 2013;8:1296, Kahlert et al. Circ. 2010;121:870, Knipp et al. Interact Cardiovasc Thorac Surg. 2013;16:116, Linke et al. TCT 2014,
Rodes-Cabau et al. JACC Cardiovasc Interv 2014;7:1146

5. The TriGuard Device
Single-wire nitinol frame and mesh filter with pore size of 130μm designed to deflect cerebral emboli during TAVR while allowing maximal blood flow
Device is positioned across all 3 cerebral vessels and maintained by a stabilizer in the innominate
Delivered via 9 Fr sheath from femoral artery

6. DEFLECT III Study Overview
Design: Multicenter prospective single-blind randomized controlled trial at 13 sites (EU/IL)
Objective: To evaluate the safety, efficacy and performance of TriGuard protection compared with unprotected TAVR.
Sample Size: Exploratory study with no formal hypothesis testing.
86 patients selected to benchmark events for the design of a pivotal RCT.
Subjects with AS undergoing TAVR
1:1 Randomization 31
:07:24 PM 4 MA MA
:07:24 PM 4 31
Embolic Protection (TriGuard)
Unprotected TAVR
(Control) 5

7. DEFLECT III Eligibility Criteria
Key Inclusion Criteria
Patients undergoing TAVR via the transfemoral approach
Exclusion Criteria
Stroke or TIA within prior 6 months
Any other cardiac intervention within prior 2 weeks
Aortic arch or innominate anatomy deemed to prevent positioning and stability of the device (ostium diameter <11 mm, transverse aortic diameter >40 mm)
Contraindication to cerebral MRI (e.g., pacemaker)

8. DEFLECT III Procedures & Assessments
Screening
Procedure
Post-Procedure
30 days
4±2 days
̴30 days
NIHSS
mRS
Neurocog*
TAVR
TriGuard
DW-MRI
NIHSS
mRS
Neurocog*
DW-MRI
NIHSS
mRS
Neurocog*
*Neurocognitive test battery includes the Montreal Cognitive Assessment (MoCA) and computerized CogState Research Test. Baseline and 30-day evaluations include supplemental Digit Symbol Substitution, Trailmaking, and Word Fluency Tests.

9. DEFLECT III Endpoints Primary Safety Endpoint (ITT population)
In-hospital MACCE defined as the composite of death, stroke, life-threatening or disabling bleeding, AKI (2/3), and major vascular complications (VARC-2)
Secondary Performance (ITT population)
Technical success: successful positioning (complete 3-vessel coverage verified by angiography) and retrieval without TAVR interference
Secondary Efficacy (ITT and Per Treatment* populations)
DW-MRI: Frequency, number, and average single, maximal, and total lesion volumes by DW-MRI at 4+2 days (range 2-6 days)
Neurocognitive: Postoperative and change from baseline to postprocedure and 30 days
*Per treatment (PT) population: subjects with complete TriGuard cerebral vessel coverage throughout the procedure (core lab adjudicated)

10. DEFLECT III Patient Disposition
Intent To Treat Population
N=83
Embolic Protection (TriGuard)
n = 45
Unprotected TAVR
(Control)
n = 38
MRI Loss to FU n=13 (29%)
Stroke n=1
Refused n = 3
PPM n=9
MRI Loss to FU n=13 (34%)
Death n = 2
Stroke/PPM n=1
Refused n = 4
PPM n=6
In-hospital FU
Safety n = 45
DW-MRI:
n = 32 (71%) (ITT)
n = 26 (57%)(PT)
In-hospital FU
Safety n = 38
DW-MRI:
n = 25 (65%) (ITT)
n = 25 (65%) (PT)

11. DEFLECT III Trial Organization
Principal
Investigators
Alexandra Lansky, MD Andreas Baumbach, MD
Yale University School of Medicine,USA Bristol Heart Institute, UK
Szilard Voros, MD (Director)
Global Institute for Research, Richmond, VA, USA
Ecaterina Cristea, MD (Director) Helen Parise, PhD
Yale University School of Medicine, New Haven, CT, USA (Statistics)
Adam Brickman, MD (Director) Kevin Abrams, MD (chief)
Columbia University, New York, USA Baptist Hospital, Miami, Fl
Michael Cleman, MD (Chair) Joseph Brennan, MD
John Forrest, MD Abeel Mangi, MD
Yale University School of Medicine, New Haven, CT, USA
Genae International, Inc.
Harvard Clinical Research Institute
MRI Core Lab
Angiographic
Core Lab
Biostatistic
Neurologic &
neurocognitive
Assessment
Clinical Events
Committee
Monitoring,
Site Mgmt.
Data Mgmt

12. DEFLECT III Trial – Enrollment Highlights
Feb 26, 2014
March 4, 2015
April 4, 2015
RCT Enrollment Complete
Enrollment Start
30 day FU
Complete
5 Countries / 13 Centers
Joachim Schofer (17)
Hamburg, Germany
Andreas Baumbach (8)
Bristol, United Kingdom
Martine Gilard (2)
Brest, France
Didier Tchetche (13)
Toulouse, France
Daniel Blackman (6)
Leeds, United Kingdom
Thomas Modine (1)
Lille, France
Pieter Stella (11)
Utrecht, Netherlands
Gil Bolotin (4)
Haifa, Israel
Michael Haude (1)
Neuss, Germany
Thomas Cuisset (10)
Marseille, France
Med Spitzer (2)
Dresden, Germany
David Hildick-Smith (1)
Brighton, United Kingdom
Jochen Reinöhl (10)
Freiburg, Germany

13. Baseline Clinical Characteristics
ITT population
TriGuard
N=45
Controls
N=38
P value
Age (y) ± SD
82.7 ± 6.5
82.5 ± 5.9
0.62
Male
40.9%
50.0%
0.41
STS Score
4.7
7.4
0.48
EuroSCORE II
10.1
0.66
NYHA Class
I or II (%)
83.3%
78.9%
0.65
III or IV (%)
45.0%
37.8%
0.85
A Fib on admission
22.0%
36%
0.36
CKD
25.0%
26.3%
0.89
COPD
31.8%
32.4%
0.95
O2 Dependent
6.8%
0.0%
0.10
Previous stroke/TIA
14.0%
18.4%
0.58
Frailty
11.9%
0.42
Porcelain Aorta
4.5%
0.18

14. *Direct Flow; **Lotus Valve
Procedure Details
ITT population
TriGuard
N=45
Controls
N=38
P value
General Anesthesia
76.7%
76.3%
0.96
Valvuloplasty Pre-TAVI
61.1%
70.4%
0.45
TAVI Implants
n=44
n=37
CoreValve
31.8%
26.3%
0.59
Edwards Sapien/3/XT
63.6%
65.8%
0.84
Other*
2.3%*
5.3%**
0.47
Total Fluoro time (min)
28.2
18.6
<0.001
Total Contrast (ml)
165.8
138.6
0.16
Adjunct Pharmacology
ASA + clopidogrel
69%
67.6%
0.89
ASA only
16.7%
16.2%
Clopidogrel only
11.9%
8.1%
0.58
Warfarin
18.9%
0.39
*Direct Flow; **Lotus Valve

15. Device Performance
ITT population
TriGuard
% (n/N)
N=45 patients
N=46 devices*
95% CI
Technical success (composite):
87 (40/46)
[68.6, 92.2]
Successful deployment
93.5 (43/46)
[82.1, 98.6]
*Successful positioning (complete 3-vessel coverage until final valve deployment of first valve, verified by QCA)
87.0 (40/46)
[73.7, 95.1]
Successful retrieval
100 (46/46)
[88.5, 99.9]
Device interference (with TAVI system)
0 (0/46)
[0.0, 7.7]
Device Failure
[0.1, 11.5]
*One subjects had 2 TriGuard devices used (valve in valve case)
*Per Treatment Population: excludes 6 patients with incomplete cerebral coverage

16. In-hospital Safety Outcomes (ITT)
ITT population
TriGuard
% (n/N)
Controls
Relative Risk
[95% CI]
Hierarchical Composite
In-hospital MACCE
22.2 (10/45)
31.6 (12/38)
0.70 [0.34, 1.45]
Death
2.2 (1/45)
5.3 (2/38)
0.42 [0.04, 4.48]
All stroke
Life-threatening bleed
AKI (Stage 2/3)
0 (0/38)
2.54 [0.11, 60.7]
Major vascular comp.
15.6 (7/45)
15.8 (6/38)
0.99 [0.36, 2.68]
Non-hierarchical components
4.4 (2/45)
0.84 [0.12, 5.71]
7.9 (3/38)
0.28 [0.03, 2.60]
17.8 (8/45)
21.1 (8/38)
0.84 [0.35, 2.04]
TAVR Device Success (VARC-2 Composite)
97.8 (44/45)
94.7 (36/38)
1.03 [0.95, 1.13]

17. DW-MRI Results – Single and Max Lesion Volume
Average # of new lesions/pt: 4.5 vs 4.0 for TG and Controls
Protection has lower SLV and MLV
19%
Better
Median Lesion Volume (mm3)
45%
19%
41% 32 25 32 25 26 25 26 25
Intention to Treat
Per Treatment

18. DW-MRI Results – Patients with No Ischemic Brain Lesions
Protection has more freedom from ischemic lesions
55%
42%
Better 32 25 26 25

19. DW-MRI Results – Percent of patients based on Total Lesion Volume (mm3) (PT)
P=0.06 for trend
Better
Percent of patients
55%
58%
78%
1-50
51-150
>150
mm3

20. DW-MRI Results – Frequency of Patients with No Ischemic Brain Lesions
Sapien
CoreValve
ITT PT
ITT PT
Better
P int.=0.08
Percent of patients
N=18
N=14
All Sapien
n=37
Sapien 3
N=22
All Sapien
n=35
Sapien 3
N=22

21. Clinical Efficacy Outcomes – NIHSS and MoCA
Protection had fewer strokes and
better cognitive outcomes
Patients with worsening NIHSS and MoCA from baseline to discharge
Worse
2/41
5/35
5/35
NIHSS
MoCA

22. MoCA Score –Change from Baseline to Discharge (ITT)
Protection prevents a decline in cognition at discharge
Better
Age Adjusted

23. Clinical Efficacy: CogState-Test Results (PT)
Protection is associated with improved short and delayed memory at discharge
Short term memory test
Delayed memory test
p=0.043
p=0.028
Age Adjusted

24. Conclusions
Use of the TriGuard was safe and provided complete cerebral coverage in 87% of cases
TriGuard protection increased the proportion of patients completely free of ischemic brain lesions by more than 50% and reduced single and maximum lesion volume by about 40%
TriGuard appears to prevent cognitive decline and was associated with improved short-term and delayed memory at discharge compared to controls
Stroke was under-reported based on systematic NIHSS assessment
Protected patients had a 10% absolute lower stroke rate
DEFLECT III provides proof of concept of the benefits of neuroprotection with the TriGuard device during TAVR and will benchmark event rates for a planned definitive randomized US approval trial

26. Death Events Event Arm Time to Event (days) Comment
Cardiovascular Death
Control
Following BAV, transfemoral placement of Edwards valve immediately followed by pericardial effusion. Sternotomy and circulatory assist performed, followed by evidence of Ao ring rupture.
Following BAV, hemodynamic instability with suspicion of Ao ring rupture. An Edwards valve was implanted prior to pt. death.
TriGuard 14
Subject with disabling ischemic stroke. Primary cause of death: pneumonia, contributing causes: cerebral multi-infarct syndrome, vascular disease and COPD.

27. Neurological Events Event Arm Time to Event (days) Comment
Ischemic Stroke,
Non-disabling
Control 1
MDT CV implanted too deep → manipulation prior to implantation. Post TAVI blurred vision, slurred speech. Resolved at 30 D F/U.
Stroke, Undetermined,
Non-Disabling 2
Edwards valve. 2 days following TAVI changes in visual field were reported. Subject was unable to fix gaze at times. Neurological consult performed. MRI not performed.
TriGuard
TriGuard maintained position, 3/3 vessels covered. Presentation included slurred speech, right sided weakness. At one month was still under neurology team care but residing at home.
Disabling
TriGuard lost position during TAVI with 0/3 vessel coverage. Prior existing TAVI device, Edwards implant. Bilateral ischemic stroke (anterior and posterior) confirmed by MRI/CT. NIHSS: 30, MRS: 5. Subject died of pneumonia day 14.

28. AKI Event rates in DEFLECT III compared to Literature
1.Takagi H, Int J Cardiol. 2013;168: ;
2. Konigstein M, Am J Cardiol. 2013;
3. Sinning JM, JACC Cardiovasc Interv. 2010;3: ;
4. Gebauer K, International journal of nephrology. 2012;2012:483748;
5. Smith CR, N Engl J Med. 2011;364: ;
6. Leon MB, New England Journal of Medicine. 2010;363: ;
7. Adams DH, N Engl J Med. 2014;370: ;
8. Popma JJ, J Am Coll Cardiol. 2014;63: ;
9. Najjar Expert Rev Cardiovasc Ther. 2015;13: ;
10. Leon MB, J Am Coll Cardiol. 2011;57: ;
11.Kappetein AP, J Am Coll Cardiol (In Press). 2012

30. Reporting Stroke: What if we ask Neurologists ?
Prospective evaluation of pts undergoing surgical AVR
Pre and post assessment and DW MRI
Clinical strokes in hospital: 17%
Moderate/severe: 4%
TIA 2%
Silent infarcts on MRI: 54%