Embrella embolic deflection device for cerebral protection during transcatheter aortic valve replacement Mariam Samim, MD, Pierfrancesco Agostoni, MD,

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Embrella embolic deflection device for cerebral protection during transcatheter aortic valve replacement Mariam Samim, MD, Pierfrancesco Agostoni, MD, PhD, Jeroen Hendrikse, MD, PhD, Ricardo P.J. Budde, MD, PhD, Freek Nijhoff, MD, Jolanda Kluin, MD, PhD, Faiz Ramjankhan, MD, Pieter A. Doevendans, MD, PhD, Pieter R. Stella, MD, PhD The Journal of Thoracic and Cardiovascular Surgery Volume 149, Issue 3, Pages 799-805.e2 (March 2015) DOI: 10.1016/j.jtcvs.2014.05.097 Copyright © 2015 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 A, The Embrella Embolic Deflector System, consisting of 2 petals and a delivery cable. This device is placed at the outer curvature of the aortic arch and the 2 petals cover the brachiocephalic trunk and the left carotid artery. B, Once positioned in the aortic arch, a contrast injection through the delivery sheet confirms proper placement of the device. Note that in this patient, the left subclavian artery also is covered by the Embrella petal. C, Unhampered passage of the valve delivery system through the aortic arch in the presence of the Embrella device. LCCA, Left common carotid artery; LSA, left subclavian artery; BCA, brachiocephalic artery. The Journal of Thoracic and Cardiovascular Surgery 2015 149, 799-805.e2DOI: (10.1016/j.jtcvs.2014.05.097) Copyright © 2015 The American Association for Thoracic Surgery Terms and Conditions

Figure 2 A, Incidence of different sizes of cerebral DWI lesions in the Embrella group compared to the TAVR-only group. DWI lesions were categorized according to volume. The majority of lesions in the Embrella group have a volume of less than 20 μL (80%), which is the case in only 54% of the TAVR-only group. B, Lesion volumes of more than 1000 μL occurred only in the TAVR-only group. C, Left/right distribution of DWI lesions. A shift toward a higher number of lesions in the right side of the brain was observed when an Embrella Embolic Deflector System was used during TAVR. DWI, Diffusion weighted magnetic resonance imaging; TAVR, transcatheter aortic valve replacement. The Journal of Thoracic and Cardiovascular Surgery 2015 149, 799-805.e2DOI: (10.1016/j.jtcvs.2014.05.097) Copyright © 2015 The American Association for Thoracic Surgery Terms and Conditions

Embrella Embolic Deflector System for brain protection during transcatheter aortic valve replacement. The Journal of Thoracic and Cardiovascular Surgery 2015 149, 799-805.e2DOI: (10.1016/j.jtcvs.2014.05.097) Copyright © 2015 The American Association for Thoracic Surgery Terms and Conditions

Figure E1 Rotational angiography image showing Embrella device (arrow) placed in the aortic arch of a patient with an arteria lusoria: anomaly of the aortic arch, with the right carotid and an aberrant right subclavian artery arising directly from the aorta. The arteria lusoria (arrow head) arises beyond the left subclavian artery. In this patient, the left and right carotid and left subclavian arteries were not covered by the Embrella device. LCCA, Left common carotid artery; LSA, left subclavian artery; RCCA, right common carotid artery; RSA, right subclavian artery. The Journal of Thoracic and Cardiovascular Surgery 2015 149, 799-805.e2DOI: (10.1016/j.jtcvs.2014.05.097) Copyright © 2015 The American Association for Thoracic Surgery Terms and Conditions

Figure E2 DWI showing a TIA-related lesion of 40 μL in the Wernick area (arrow head). The patient suffered from transient signs of dysphasia. The Journal of Thoracic and Cardiovascular Surgery 2015 149, 799-805.e2DOI: (10.1016/j.jtcvs.2014.05.097) Copyright © 2015 The American Association for Thoracic Surgery Terms and Conditions