The Tryton Bifurcation Trial: A randomized comparison of a provisional one-stent vs. a dedicated two-stent strategy for true bifurcation coronary lesions Martin B. Leon, MD for the Tryton Bifurcation Trial Investigators Columbia University Medical Center Cardiovascular Research Foundation New York City Wednesday, October 30, 2013

Disclosure Statement of Financial Interest TCT 25: San Francisco, CA; Oct 27 - Nov 1, 2013 Martin B. Leon, MD Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) listed below. Affiliation/Financial Relationship Company Research Support (CUMC) Consulting Fees/Honoraria Major Stock Shareholder/Equity Abbott, Boston Scientific, Medtronic None

Tryton Side Branch Stent 8 mm 4.5 mm 6.5 mm Main Branch Zone Transition Zone Side Branch Zone Tryton is a Cobalt alloy bare metal stent

Tryton Study Design Baseline Angiography – Eligible for Randomization    Tryton side branch + DES (main vessel) DES (main vessel) + Provisional side branch N = 704   TVF Primary Endpoint Clinical F/U at 9 months Clinical F/U at 9 months   Angiographic F/U at 9 months % DS side branch n~374 Angiographic F/U at 9 months   IVUS F/U at 9 months IVUS Cohort n~96 IVUS F/U at 9 months

Primary and Secondary Endpoints Study design: Intention-to-treat (ITT) is primary analysis cohort, 1:1 randomization Primary Endpoint: Target vessel failure @ 9 months follow-up (all patients): non-inferiority cardiac death target vessel MI (peri-procedural > 3X CK-MB) target vessel revascularization (ischemia-driven, main vessel or side branch) Secondary Endpoint: % diameter stenosis (in-segment) of side branch at 9 months follow-up (angiographic cohort only): superiority

Medina Classification (Core Lab) “True” Bifurcation T: 89.9% P: 86.2% T:49.2% P:42.1% T:15.8% P:16.0% T: 24.9% P: 28.1% T: 1.4% P: 2.6% T: 2.3% P: 4.9% T: 2.8% P: 4.0% T: 3.4% P:2.3% Table 8a Core Lab run date 5 Sept 2013 FULL Cohort P = Provisional T = Tryton

Additional Side Branch Stents (Site Reported) Provisional (n= 349) 28 (8.0%) Tryton (n= 355) 3 (0.9%) 7 (2.0%) Tryton Prox at lesion (3/0.9%) Distal (7/2.0%) Provisional: Prox/at lesion (23/6.6%), Distal (6/1.7%) At target (Proximal Distal) Additional Stent Table

Target Vessel Failure (TVF)* Primary Endpoint % Provisional Tryton P=0.108 Verified DF, Table B1 Run Date 30 Sep 2013, p 4 of 131, Tables and Figures from HCRI 14-Oct-13 * TVF = Cardiac death, TV–MI and TVR

Target Vessel Failure (TVF) Primary Endpoint % P= 0.108 Provisional Tryton P = 0.109 P =0.564 Verified DF, Table B1 Run 30 Sept 2013, page 4 of 131, Tables and Figures from HCRI 14-Oct-2013 Non Hierarchical

Side Branch %DS (In-segment) Secondary Endpoint Provisional Tryton P=0.002 Verified DF, Table 1 Run Date 30 Sept 2013, page 3 of 131, Tables and Figures from HCRI 14-Oct-13 Secondary Superiority Endpoint Met

Target Vessel Failure (TVF) Side Branch ≥ 2.25 mm % P= 0.383 Provisional Tryton P = 0.563 P =0.769 LARGE VESSEL Table B1.b req20 Tb1.B2 Hierarchical TVF RVD 225 b Run Date 15 Oct 2013 proofed lll Non Hierarchical

Angiographic Outcomes (QCA) Side Branch ≥ 2.25 mm % Provisional Tryton P = 0.004 P = 0.260 Binary Restenosis: Table 14b Run date 15 Oct 2013 entered df verified lll %Diameter Stenosis: Table 1b. Primary Endpoint SB RVD >=2.25 15Oct 13 entered df verified lll Provisional (N=81) Tryton (N=63)

Conclusions The Tryton two-stent strategy in true bifurcations (88%) compared with the provisional strategy (8.0% side branch stents) did not meet the non-inferiority clinical endpoint (TVF), due to a relatively higher frequency of small peri-procedural CK-MB elevations. However, both strategies were safe (rare clinically significant MIs and stent thrombosis) and both had low 9-month clinically-driven TVR (P:3.6%,T:4.7%). DES in the main vessel performed well in both arms. Tryton improved side branch % diameter stenosis at FU (secondary endpoint; P=0.002)

Conclusions Post-hoc subset analyses indicated: A striking disparity between binary restenosis and clinically-driven TVR for both arms, indicating that side branch angiographic restenosis is uncommonly expressed clinically. Improved clinical and angiographic outcomes with Tryton in larger side branches (> 2.25 mm side branches = 41% of enrolled patients).

Clinical Implications It’s difficult to enroll complex “high-risk” bifurcation lesions in clinical trials (only 41% had side branches ≥ 2.25 mm). Small peri-procedural CK-MB elevations occur more frequently with a two-stent strategy and dominate the clinical endpoint (TVF). Moderate stenoses in smaller side branches are not clinically active (occulostenotic paradox). In larger side branches (≥ 2.25 mm), a Tryton two-stent strategy improved side branch angiographic results and clinical outcomes.