Second Generation Valves: What Will Be Different? Ian T. Meredith MBBS, BSc(Hons), Ph.D, FRACP, FACC, FCSANZ, FSCAI, FAHA, FAPSIC Professor and Director of Monash HEART Southern Health & Monash University, Melbourne Australia

Ian T Meredith, MD, PhD Honoraria: Abbott Vascular Boston Scientific Corporation Medtronic, Inc.

Current Clinical Concerns Performance Paravalvular AR Size and Deliverability Learning Curve and Ease of Use Clinical Events Stroke Bleeding Vascular Complications Mortality by Grade of AR -Sinning JM, et. al., EuroPCR 2011 Leon M, ACC 2011

Current Technology Gaps Matrix of Device Sizes Commercially Available Device Repositioning/retrievability Paravavular Leakeage Device Preparation challenges

Second Generation TAVR Systems Transfemoral Direct Flow Medical St. Jude Medical AorTx Heart Leaflet EndoTech ABPS PercValve Lotus Valve Valve Medical

Second Generation TAVR Systems Transapical Jena Valve Ventor Symetis

Sadra-BSC Lotus™ Valve System Second generation TAVR system designed to address gaps with first generation systems Valve pre-attached to delivery system Easy device preparation Repositionable – proximal or distal for controlled and accurate valve placement Retrievable at any point up to release Valve functions early in deployment Adaptive seal designed to minimize paravalvular leakage

Sadra-BSC Lotus™ Valve Delivery System Easy to Prepare Pre-Loaded System Deploy, Lock Release Unlock, Retrieve Intuitive Handle Design 2 Controls Release

Sadra-BSC Lotus™ Valve Lotus™ Valve Pre-Loaded System Locking Mechanism Enables operator control of implant Nitinol Frame Designed for retrieval and repositioning Bovine Pericardium Long-term proven material Adaptive Seal Designed to minimize perivalvular leaks

The Lotus™ Valve System Product Design Goal Attributes Compared to First Generation Devices Edwards Sapien™ XT Medtronic CoreValve® BSC / Sadra Lotus™ Pre-loaded Delivery System   Reversibility of Deployment partial 1 Bovine Tissue Leaflet Material (porcine tissue) ≤18F Profile Paravalvular Sealing Component 1 - Retrievable up to and including full deployment, and prior to the implant release from the delivery system. Other Sources: Edwards.com, Medtronic.com, Sadramedical.com; The Lotus Valve System is an investigational device, not available for sale. Sapien and CoreValve are investigational devices in the U.S., and not approved for sale. See Glossary

The Lotus™ Valve System Procedure Steps Delivery Unsheathing Locking Assessment Release Final Result Release Images from Lotus Feasibility Study, 2010, HELIOS Klinikum Siegberg

The Lotus™ Valve System Repositionable and Retrievable Complete assessment is performed while valve is fully locked and still attached to the delivery system Unlock Resheath Complete Recapture Enabling repositioning or full recapture

Sadra-BSC Lotus™ Valve 21 Fr FIM – 1 Year Follow-up

Sadra-BSC Lotus™ Valve 18 Fr Feasibility Study– 1 Year Follow-up

The Lotus™ Valve System REPRISE I Feasibility Study Objective Assess acute safety and performance of Lotus™ Valve System for TAVR in patients with aortic valve stenosis at high risk for surgical intervention Primary endpoint: Clinical procedural success, defined as device success without in-hospital MACCE Valve Size 23 mm valve  aortic annulus size 19-22 mm Sites: Monash Medical Center Royal Adelaide St. Vincent’s Hospital Prof. Ian Meredith (Principal Investigator) Prof. Rob Whitbourn Prof. Stephen Worthley

The Lotus™ Valve System REPRISE II Clinical Trial Objective Evaluate safety & performance of Lotus™ Valve System in patients with severe aortic stenosis at high risk for surgery Primary endpoint Device performance: 30-day Mean aortic valve pressure gradient Safety: 30-day all cause mortality Enrollment Up to 120 patients in Australia, France, Germany, UK Two valve sizes 23 mm  aortic annulus size 19-22 mm 27 mm  aortic annulus size 23-26 mm Rigor to support regulatory approvals

Sadra-BSC Lotus™ Valve REPRISE II Study VARC endpoints and definitions Patient selection with Case Review Committee oversight Frailty: Nutritional assessment Grip strength Gait speed Activities of daily living Cognitive function Physical activity Comprehensive aortic valve and iliofemoral analyses Modified Rankin Score at baseline and all follow-up visits, 30-day and 90-day after a neurological event Long term QOL assessments (baseline, 6 mo, 1, 3 and 5 yrs)

REPRISE II Patients’ Screening - Valve and Femoral Anatomy 18

Conclusions TAVR results in  both symptomatic and prognostic improvement in elderly high risk patients with severe symptomatic aortic stenosis who would otherwise be treated medically Adverse events with first generation TAVR systems highlight opportunities to improve upon current outcomes The Lotus™ Valve System is designed to address many of the current challenges with first generation technology The REPRISE I and II clinical trials will assess the safety and performance of the Lotus Valve replacement system