Screening Patients for the Transcatheter Aortic Valve Replacement (TAVR) Procedure. A Guide for Referring Physicians

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Bartholomew Horton
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1 Screening Patients for the Transcatheter Aortic Valve Replacement (TAVR) Procedure A Guide for Referring Physicians

TAVR Patient Screening Flow 1 2 3 Patient is

evaluated using echocardiography The aortic

2 TAVR Patient Screening Flow Patient is diagnosed with symptomatic severe native calcific aortic stenosis and referred to the Heart Team for evaluation The aortic valvular complex is evaluated using echocardiography The aortic valvular complex and peripheral vasculature are evaluated using MDCT

3 4 5 6 The aortic valvular complex and peripheral vasculature are evaluated using catheterization Patient is evaluated by the Heart Team and meets the indication for TAVR Appropriate access route for TAVR procedure is determined by the Heart Team The above is a suggested flow for the patient screening process, however, the order in which screening tests are conducted varies depending on the patient s profile and should be at the discretion of the Heart Team.

This guide provides an overview of the screening

for transcatheter aortic valve replacement

heart valve. Please visit www.newheartvalve.

4 This guide provides an overview of the screening process used by Heart Teams to evaluate patients for transcatheter aortic valve replacement (TAVR) with the Edwards SAPIEN XT transcatheter heart valve. Please visit to locate a Heart Team and TAVR center near you.

1 Patient is Diagnosed with Symptomatic Severe Native Calcific Aortic Stenosis An Overview of the 2014 AHA/ACC Valvular Heart Disease Guidelines - Symptomatic Severe Aortic Stenosis 1 Symptoms of

5 1 Patient is Diagnosed with Symptomatic Severe Native Calcific Aortic Stenosis An Overview of the 2014 AHA/ACC Valvular Heart Disease Guidelines - Symptomatic Severe Aortic Stenosis 1 Symptoms of severe aortic stenosis include: dyspnea or decreased exercise tolerance, heart failure, angina, syncope and presyncope. Patients with severe aortic stenosis typically have an aortic valve area < 1.0 cm 2 Hemodynamic Stage Definition Valve Hemodynamics Consequences D: Symptomatic Severe Aortic Stenosis 50% After the onset of symptoms, patients with severe aortic stenosis have a survival rate as low as 50% at 2 years without aortic valve replacement. 2 D1 High-gradient Aortic jet velocity > 4m/s or mean gradient > 40 mmhg Or aortic valve area index < 0.6 cm 2 /m 2 Left ventricular diastolic dysfunction Left ventricular hypertrophy Pulmonary hypertension may be present D2 Low-flow/low-gradient with reduced left ventricular ejection fraction Resting aortic jet velocity < 4m/s or mean gradient < 40 mmhg Dobutamine stress echocardiography shows aortic valve area < 1.0 cm 2 with aortic jet velocity > 4m/s at any flow rate Left ventricular diastolic dysfunction Left ventricular hypertrophy Left ventricular ejection fraction < 50% D3 Low-gradient with normal left ventricular ejection fraction or paradoxical low-flow Aortic jet velocity < 4m/s or mean gradient < 40 mmhg Stroke volume index < 35 ml/m 2 measured when patient is normotensive (systolic blood pressure < 140 mmhg) Increased left ventricular relative wall thickness Small left ventricular chamber with low stroke volume Restrictive diastolic filling Left ventricular ejection fraction > 50%

2 The Aortic Valvular Complex is Evaluated Using Echocardiography After a patient is diagnosed with symptomatic severe native calcific aortic stenosis, patients will need various imaging tests to

Comprehensive imaging tests will assess: the aortic valvular complex, cardiac structures and function, aortic arch, and peripheral vessels.

6 2 The Aortic Valvular Complex is Evaluated Using Echocardiography After a patient is diagnosed with symptomatic severe native calcific aortic stenosis, patients will need various imaging tests to assess if they are appropriate candidates for the transcatheter heart valve and delivery method. Comprehensive imaging tests will assess: the aortic valvular complex, cardiac structures and function, aortic arch, and peripheral vessels. Transthoracic Echocardiography (TTE) is generally the first approach in assessing the annulus size due to its non-invasiveness TTE underestimates the annulus size and is typically used to obtain an estimation of annulus size Transesophageal Echocardiography (TEE) is used to confirm annulus size when TTE measurements are borderline or the image quality is poor A B TTE (A) should occur in a parasternal long-axis view 3 TEE (B) should occur in a left ventricular long-axis view (~120 ) 3

Transesophageal Echocardiography is used to

annulus size is assessed by TEE: Measurements are

points of the native valve leaflets at the

positioned between the left and non-coronary

7 Transesophageal Echocardiography is used to evaluate the size of the aortic annulus When the annulus size is assessed by TEE: Measurements are taken during systole at the plane of the hinge points of the native valve leaflets at the largest diameter The long-axis plane is positioned between the left and non-coronary cusps and through the right coronary cusp Systole Diastole Oblique Measurement

3 The Aortic Valvular Complex and Peripheral Vasculature are Evaluated Using MDCT Gated Multi-Detector Computed Tomography (MDCT) is used to evaluate the size of the aortic

annulus is a dynamic structure that changes shape during the cardiac cycle: 5 Largest during systole Smaller and more ovoid during diastole It is critical to obtain accurate

Slice thickness of heart (less than) 1 mm Dose modulation switched off or only used for diastole (drop in diastole increase in systole) Sinotubular Junction Aortic Leaflets

8 3 The Aortic Valvular Complex and Peripheral Vasculature are Evaluated Using MDCT Gated Multi-Detector Computed Tomography (MDCT) is used to evaluate the size of the aortic annulus Annulus assessment via ECG-gated cardiac MDCT and 3D echocardiography allows the evaluation of the annulus in an orthogonal plane at the level of the basal ring 4 The annulus is a dynamic structure that changes shape during the cardiac cycle: 5 Largest during systole Smaller and more ovoid during diastole It is critical to obtain accurate sizing measurements and it is recommended to use a systolic series obtained from MDCT Patient is not moving during acquisition ECG triggered or gated CT Contrast-enhanced Slice thickness of heart (less than) 1 mm Dose modulation switched off or only used for diastole (drop in diastole increase in systole) Sinotubular Junction Aortic Leaflets Virtual Ring formed by joining basal attachments of aortic leaflets Reconstruct in 5-10% increments from 25% - 45% of the R-R interval which helps ensure the maximum area is determined

14 mm 17 mm 19 mm 23 mm THV Size to Annulus Size* 26 mm 29 mm THV Size 23 mm 26 mm 29 mm Native Valve Annulus Size (TEE) 18-22 mm 21-25 mm 24-27 mm Native Valve Annulus Size (CT) Area 314-415 mm 2

9 14 mm 17 mm 19 mm 23 mm THV Size to Annulus Size* 26 mm 29 mm THV Size 23 mm 26 mm 29 mm Native Valve Annulus Size (TEE) mm mm mm Native Valve Annulus Size (CT) Area mm mm mm 2 Native Valve Annulus Size (CT) Area Derived Diameter mm mm mm *THV size recommendations are based on native valve annulus size, as measured by transesophageal echocardiography (TEE) or computed tomography (CT). Patient anatomical factors and multiple imaging modalities should be considered during THV size selection. Note: Risks associated with undersizing and oversizing should be considered.

preoperative chest CT may be helpful in determining the orientation of the apex to determine suitability for access For

10 3 The Aortic Valvular Complex and Peripheral Vasculature are Evaluated Using MDCT Gated MDCT is used to evaluate the aortic valvular complex: Location and extent of leaflet calcification is evaluated For transapical patients, preoperative chest CT may be helpful in determining the orientation of the apex to determine suitability for access For transaortic patients, preoperative chest CT may be helpful in determining the anatomical relationship of the sternum and ascending aorta 6

MDCT is used to evaluate the peripheral vasculature to determine patient appropriateness for the transfemoral procedure: Minimum lumen diameters should be measured along the length of the common

11 MDCT is used to evaluate the peripheral vasculature to determine patient appropriateness for the transfemoral procedure: Minimum lumen diameters should be measured along the length of the common femoral, external iliac and common iliac arteries Internal diameter measurements should not include calcium Recommended Minimum Vessel Diameters for Implantation of the Edwards SAPIEN XT Transcatheter Heart Valve Edwards SAPIEN XT THV Size Suggested minimum vessel size 23 mm 26 mm 29 mm 6 mm 6.5 mm 7 mm esheath profile 16F 18F 20F Note: For patients with renal failure, non-contrast CT or IVUS of the iliac may be used to evaluate the extent of calcification in the vessel and estimate vessel diameter

calcification and tortuosity of the peripheral vasculature Qualitative assessment of

12 4 The Aortic Valvular Complex and Peripheral Vasculature are Evaluated Using Catheterization The following may be evaluated using catheterization: Degree of calcification and tortuosity of the peripheral vasculature Qualitative assessment of angulation and degree of stenosis of the aortic arch and distance of the coronary ostia from the aortic annulus

13 Assessment of the coronary arteries to determine if revascularization is necessary

5 Patient is Evaluated by the Heart Team and Meets the Indication for TAVR According to the National Coverage Determination Memo published by the Centers for Medicare and Medicaid Services (CMS), two

rationale for their clinical judgement and make this rationale available to the Heart Team.

14 5 Patient is Evaluated by the Heart Team and Meets the Indication for TAVR According to the National Coverage Determination Memo published by the Centers for Medicare and Medicaid Services (CMS), two cardiac surgeons must independently examine the patient face-to-face and evaluate the patient s suitability for open aortic valve replacement surgery; both surgeons are required to document the rationale for their clinical judgement and make this rationale available to the Heart Team. HIGH OR GREATER RISK PATIENTS: who are judged by a Heart Team, including a cardiac surgeon, may be considered for TAVR if they have an STS operative risk score of 8% or are at a 15% risk of mortality at 30 days. See page 18 and 19 for indications and Important Risk Information. In addition, some patients may have a low STS score but present with co-existing conditions that prevent the patient from being a suitable candidate for surgery. These conditions include 7 : Extensively calcified (porcelain) aorta Chest wall deformity Oxygen-dependent respiratory insufficiency Frailty

15 6 Appropriate Access Route for Aortic TAVR Procedure is Determined Transfemoral Approach Transapical Approach Transaortic Approach

6 Appropriate Access Route for Aortic TAVR Procedure is Determined Anatomy Diameter of iliac and femoral arteries Transfemoral Approach Recommended Femoral and iliac arteries 6 mm for 23 mm valve, 6.

16 6 Appropriate Access Route for Aortic TAVR Procedure is Determined Anatomy Diameter of iliac and femoral arteries Transfemoral Approach Recommended Femoral and iliac arteries 6 mm for 23 mm valve, 6.5 mm for 26 mm valve and 7 mm for 29 mm valve Calcification of iliac and femoral arteries Tortuosity of iliac and femoral arteries Ventricle Aorta No significant calcification of the femoral or iliac arteries No significant calcification of the aortic bifurcation No severe tortuosity of the arterial pathway from the femoral artery to the aortic bifurcation Severe LV dysfunction Hostile apex LV aneurysm Dyskinetic ventricle Quality of the tissue frail, immunosuppressed patients Myocardial injury Severe COPD No significant aortic disease, including no aneurysm, no presence of severe tortuosity and/or narrowing No horizontal aortic root and vertical valve plane No acute aortic arch angulation No aortic arch atheroma

17 Transapical Approach Recommended Femoral and/or iliac arteries < 6 mm for 23 mm valve, < 6.5 mm and for 26 mm valve, and < 7 mm for 29 mm valve Iliofemoral bypass Extensive calcification of the femoral and/or iliac arteries Extensive calcification of aortic bifurcation Severe tortuosity of the arterial pathway from the femoral artery to the aortic bifurcation Free from pericardial disease or dyskinetic or aneurysmal ventricular apex Significant aortic disease including aneurysm, severe tortuosity and/or narrowing Horizontal aortic root without vertical valve plane Acute aortic arch angulation Aortic arch atheroma Significant aortic valve calcification with bulky leaflets wherein retrograde crossing may be problematic Transaortic Approach Recommended Femoral and/or iliac arteries < 6 mm for 23 mm valve, < 6.5 mm and for 26 mm valve, and < 7 mm for 29 mm valve Iliofemoral bypass Extensive calcification of the femoral and/or iliac arteries Extensive calcification of aortic bifurcation Severe tortuosity of the arterial pathway from the femoral artery to the aortic bifurcation Severe LV dysfunction Hostile apex LV aneurysm Dyskinetic ventricle Quality of the tissue frail, immunosuppressed patients Myocardial injury Severe COPD Adequate distance from puncture to aortic annular plane (5.0 cm for 23 mm valve, 5.5 cm for 26 mm valve and 6.0 cm for 29 mm valve) No significant aortic disease, including no aneurysm No aortic arch atheroma No excessive calcification of aorta at access site

Why recommend an Edwards transcatheter heart valve for your patient? The Edwards SAPIEN transcatheter heart valve platform is designed to imitate surgical valves in design and outcomes.

Designed for Durability Edwards transcatheter heart valves use proven tissue and leverage the manufacturing processes of our leading surgical heart valves which have over 20 years of durability data.

18 Why recommend an Edwards transcatheter heart valve for your patient? The Edwards SAPIEN transcatheter heart valve platform is designed to imitate surgical valves in design and outcomes. They are the most widely used transcatheter heart valves worldwide and consistently demonstrate clinical excellence in both trials and real-world experience. Designed for Durability Edwards transcatheter heart valves use proven tissue and leverage the manufacturing processes of our leading surgical heart valves which have over 20 years of durability data. Low Incidence of Complications and Permanent Pacemakers Low frame height minimizes the risk of coronary obstruction and conduction system interference. SAPIEN valves consistently demonstrate low rates of permanent pacemaker implantation. Optimal Hemodynamic Performance The balloon-expandable, high radial strength frame is designed to achieve circularity* at the annulus to maximize area and flow while promoting full expansion and apposition at the annulus to minimize aortic regurgitation. The Edwards SAPIEN XT transcatheter heart valve, model 9300TFX, systems are indicated for relief of aortic stenosis in patients with symptomatic heart disease due to severe native calcific aortic stenosis (aortic valve area 1.0 cm 2 or aortic valve area index 0.6 cm 2 /m 2, a mean aortic valve gradient of 40 mmhg, or a peak aortic-jet velocity of 4.0 m/s), and with native anatomy appropriate for the 23, 26, or 29 mm valve system, who are judged by a heart team, including a cardiac surgeon, to be at high or greater risk for open surgical therapy (i.e., Society of Thoracic Surgeons operative risk score 8% or at a 15% risk of mortality at 30 days). *Data on file at Edwards Lifesciences

19 IMPORTANT RISK INFORMATION Available Valve Sizes 23 mm 26 mm 29 mm The 23 mm, 26 mm, and 29 mm sizes of the Edwards SAPIEN XT valve are designed to treat an annulus size range of mm on TEE and mm on CT.

20 References 1. Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP III, Guyton RA,O Gara PT, Ruiz CE, Skubas NJ, Sorajja P, Sundt TM III, Thomas JD, 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary, Journal of the American College of Cardiology (2014), doi: /j.jacc Otto CM. Timing of aortic valve surgery. Heart. 2000;84: Delgado, V, et al. Pre-Operative Aortic Valve Implantation Evaluation: Multimodality Imaging. EuroIntervention Supplement 6.G (2010): G Leipsic, Jonathon, Gurvitch, Ronen, et.al. Multidetector Computed Tomography in Transcatheter Aortic Valve Implantation. JACC. 2011; 4(4): Achenbach, Stephan, Victoria Delgado, Jörg Hausleiter, Paul Schoenhagen, James K. Min, and Jonathon A. Leipsic. SCCT Expert Consensus Document on Computed Tomography Imaging before Transcatheter Aortic Valve Implantation (TAVI)/transcatheter Aortic Valve Replacement (TAVR). Journal of Cardiovascular Computed Tomography 6.6 (2012): Bapat V, Attia R., Transaortic Transcatheter Aortic Valve Implantation: Step-by-Step Guide., Semin Thorac Cardiovasc Surg Autumn;24(3): Leon M, et al. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med. 2010;363(17): See accompanying Important Risk Information. CAUTION: Federal (United States) law restricts these devices to sale by or on the order of a physician. See Important Risk Information for full prescribing information, including indications, contraindications, warnings, precautions and adverse events. Edwards, Edwards Lifesciences, the stylized E logo, Edwards SAPIEN, Edwards SAPIEN XT, esheath, NewHeartValve.com, SAPIEN and SAPIEN XT are trademarks of Edwards Lifesciences Corporation. All other trademarks are the property of their respective owners Edwards Lifesciences Corporation. All rights reserved. AR11852 Edwards Lifesciences I edwards.com One Edwards Way I Irvine, California USA Switzerland I Japan I China I Brazil I Australia I India

21 IMPORTANT RISK INFORMATION EDWARDS SAPIEN XT TRANSCATHETER HEART VALVE WITH THE NOVAFLEX+ DELIVERY SYSTEM Indications: The Edwards SAPIEN XT Transcatheter Heart Valve, model 9300TFX, systems are indicated for relief of aortic stenosis in patients with symptomatic heart disease due to severe native calcific aortic stenosis (aortic valve area 1.0 cm 2 or aortic valve area index 0.6 cm 2 /m 2, a mean aortic valve gradient of 40 mmhg, or a peak aortic-jet velocity of 4.0 m/s), and with native anatomy appropriate for the 23, 26, or 29 mm valve system, who are judged by a heart team, including a cardiac surgeon, to be at high or greater risk for open surgical therapy (i.e., Society of Thoracic Surgeons operative risk score 8% or at a 15% risk of mortality at 30 days). Contraindications: The THV and delivery systems are contraindicated in patients who cannot tolerate an anticoagulation/antiplatelet regimen or who have active bacterial endocarditis or other active infections. Warnings: Observation of the pacing lead throughout the procedure is essential to avoid the potential risk of pacing lead perforation. There is an increased risk of stroke in transcatheter aortic valve replacement procedures, as compared to balloon aortic valvuloplasty or other standard treatments. The devices are designed, intended, and distributed for single use only. Do not resterilize or reuse the devices. There are no data to support the sterility, nonpyrogenicity, and functionality of the devices after reprocessing. Incorrect sizing of the THV may lead to paravalvular leak, migration, embolization and/or annular rupture. Accelerated deterioration of the THV may occur in patients with an altered calcium metabolism. Prior to delivery, the THV must remain hydrated at all times and cannot be exposed to solutions other than its shipping storage solution and sterile physiologic rinsing solution. THV leaflets mishandled or damaged during any part of the procedure will require replacement of the THV. Caution should be exercised in implanting a THV in patients with clinically significant coronary artery disease. Patients with preexisting mitral valve devices should be carefully assessed prior to implantation of the THV to ensure proper THV positioning and deployment. Do not use the THV if the tamper evident seal is broken, the storage solution does not completely cover the THV, the temperature indicator has been activated, the THV is damaged, or the expiration date has elapsed. Do not mishandle the NovaFlex+ delivery system or use it if the packaging or any components are not sterile, have been opened or are damaged (e.g., kinked or stretched), or the expiration date has elapsed. Use of excessive contrast media may lead to renal failure. Measure the patient s creatinine level prior to the procedure. Contrast media usage should be monitored. Patient injury could occur if the delivery system is not un-flexed prior to removal. Care should be exercised in patients with hypersensitivities to cobalt, nickel, chromium, molybdenum, titanium, manganese, silicon, and/or polymeric materials. The procedure should be conducted under fluoroscopic guidance. Some fluoroscopically guided procedures are associated with a risk of radiation injury to the skin. These injuries may be painful, disfiguring, and long-lasting. THV recipients should be maintained on anticoagulant/antiplatelet therapy, except when contraindicated, as determined by their physician. This device has not been tested for use without anticoagulation. Do not add or apply antibiotics to the storage solution, rinse solutions, or to the THV. Precautions: Long-term durability has not been established for the THV. Regular medical follow-up is advised to evaluate THV performance. Glutaraldehyde may cause irritation of the skin, eyes, nose and throat. Avoid prolonged or repeated exposure to, or breathing of, the solution. Use only with adequate ventilation. If skin contact occurs, immediately flush the affected area with water; in the event of contact with eyes, seek immediate medical attention. For more information about glutaraldehyde exposure, refer to the Material Safety Data Sheet available from Edwards Lifesciences. To maintain proper valve leaflet coaptation, do not overinflate the deployment balloon. Appropriate antibiotic prophylaxis is recommended post-procedure in patients at risk for prosthetic valve infection and endocarditis. Safety, effectiveness, and durability have not been established for valve-invalve procedures. Safety and effectiveness have not been established for patients with the following characteristics/comorbidities: non-calcified aortic annulus, severe ventricular dysfunction with ejection fraction < 20%, congenital unicuspid or congenital bicuspid aortic valve, mixed aortic valve disease (aortic stenosis and aortic regurgitation with predominant aortic regurgitation > 3+), pre-existing prosthetic heart valve or prosthetic ring in any position, severe mitral annular calcification (MAC), severe (> 3+) mitral insufficiency, or Gorlin syndrome, blood dyscrasias defined as: leukopenia (WBC < 3000 cells/ml), acute anemia (Hb < 9 g/dl), thrombocytopenia (platelet count <50,000 cells/ ml),or history of bleeding diathesis or coagulopathy, hypertrophic cardiomyopathy with or without obstruction (HOCM), echocardiographic evidence of intracardiac mass, thrombus, or vegetation, a known hypersensitivity or contraindication to aspirin, heparin, ticlopidine (Ticlid ), or clopidogrel (Plavix ), or sensitivity to contrast media, which cannot be adequately premedicated, significant aortic disease, including abdominal aortic or thoracic aneurysm defined as maximal luminal diameter 5 cm or greater; marked tortuosity (hyperacute bend), aortic arch atheroma (especially if thick [> 5 mm], protruding, or ulcerated) or narrowing (especially with calcification and surface irregularities) of the abdominal or thoracic aorta, severe unfolding and tortuosity of the thoracic aorta, access characteristics that would preclude safe placement of 16F, 18F, or 20F Edwards Expandable Introducer Sheath Set, such as severe obstructive calcification, severe tortuosity or diameter less than 6 mm, 6.5 mm, or 7 mm, respectively, bulky calcified aortic valve leaflets in close proximity to coronary ostia. Potential Adverse Events: Potential risks associated with the overall procedure including potential access complications associated with standard cardiac catheterization, balloon valvuloplasty, the potential risks of conscious sedation and/or general anesthesia, and the use of angiography: death; stroke/transient ischemic attack, clusters or neurological deficit; paralysis; permanent disability; respiratory insufficiency or respiratory failure; hemorrhage requiring transfusion or intervention; cardiovascular injury including perforation or dissection of vessels, ventricle, myocardium or valvular structures that may require intervention; pericardial effusion or cardiac tamponade; embolization including air, calcific valve material or thrombus; infection including septicemia and endocarditis; heart failure; myocardial infarction; renal insufficiency or renal failure; conduction system defect which may require a permanent pacemaker; arrhythmia; retroperitoneal bleed; AV fistula or pseudoaneurysm; reoperation; ischemia or nerve injury; restenosis; pulmonary edema; pleural effusion; bleeding; anemia; abnormal lab values (including electrolyte imbalance); hypertension or hypotension; allergic reaction to anesthesia, contrast media, or device materials; hematoma; syncope; pain or changes at the access site; exercise intolerance or weakness; inflammation; angina; heart murmur; fever. Additional potential risks associated with the use of the THV, delivery system, and/or accessories include: cardiac arrest; cardiogenic shock; emergency cardiac surgery; cardiac failure or low cardiac output; coronary flow obstruction/transvalvular flow disturbance; device thrombosis requiring intervention; valve thrombosis; device embolization; device migration or malposition requiring intervention; valve deployment in unintended location; valve stenosis; structural valve deterioration (wear, fracture, calcification, leaflet tear/tearing from the stent posts, leaflet retraction, suture line disruption of components of a prosthetic valve, thickening, stenosis); device degeneration; paravalvular or transvalvular leak; valve regurgitation; hemolysis; device explants; nonstructural dysfunction; mechanical failure of delivery system, and/or accessories, non-emergent reoperation. EDWARDS BALLOON CATHETER (9350BC20 and 9350BC23) Indications: The Edwards balloon catheter is indicated for valvuloplasty of a stenotic aortic valve prior to implantation of the Edwards SAPIEN and SAPIEN XT transcatheter heart valves. Contraindications: Other than standard risks associated with insertion of a cardiovascular catheter, there are no known contraindications for valvuloplasty. The patient s medical condition could affect successful use of this catheter. Warnings: The device is designed, intended, and distributed for single use only. Do not resterilize or reuse the device. There are no data to support the sterility, nonpyrogenicity, and functionality of the device after reprocessing. Do not mishandle the device or use it if the packaging or any components are not sterile, have been opened or are damaged (e.g. kinked or stretched), or the expiration date has elapsed. Precautions: For special considerations associated with the use of this device prior to transcatheter heart valve implantation, refer to the bioprosthesis Instructions for Use (IFU). Use only appropriate balloon inflation medium. Do not use air or gaseous medium to inflate the balloon. The device is not intended for post-dilatation of deployed transcatheter heart valves. While exposed within the body, device advancement and retrieval should not be done without the aid of fluoroscopy. Do not advance or retract the device unless the balloon is fully deflated under vacuum. Potential Adverse Events: Complications associated with standard catheterization, balloon valvuloplasty, and the use of angiography include, but are not limited to, allergic reaction to anesthesia or to contrast media, injury including perforation or dissection of vessels, thrombus formation, plaque dislodgement and embolization that may result in myocardial infarction, stroke, distal peripheral occlusion and/or death, arrhythmia development, cardiac perforation, conduction system injury, hematoma, infundibulum injury, annular tear or rupture and/or valve leaflet dehiscence, severe valve insufficiency, valve restenosis, valve damage, balloon rupture, balloon separation following balloon rupture, valvular tearing or trauma, thromboembolic events, and infection. Reference the Edwards SAPIEN Transcatheter Heart Valve with RetroFlex 3 Delivery System, or the Edwards SAPIEN XT Transcatheter Heart Valve with the NovaFlex+ Delivery System Instructions for Use, for a full list of potential adverse events. EDWARDS BALLOON CATHETER (9350BC25) Indications: The Edwards balloon catheter is indicated for valvuloplasty of a stenotic aortic valve prior to implantation of the Edwards SAPIEN XT transcatheter heart valve. Contraindications: Other than standard risks associated with insertion of a cardiovascular catheter, there are no known contraindications for valvuloplasty. The patient s medical condition could affect successful use of this catheter. Warnings: The device is designed, intended, and distributed for single use only. Do not resterilize or reuse the device. There are no data to support the sterility, nonpyrogenicity, and functionality of the device after reprocessing. Do not mishandle the device or use it if the packaging or any components are not sterile, have been opened or are damaged (e.g. kinked or stretched), or the expiration date has elapsed. Precautions: For special considerations associated with the use of this device prior to transcatheter heart valve implantation, refer to the bioprosthesis Instructions for Use. Use only appropriate balloon inflation medium. Do not use air or gaseous medium to inflate the balloon. The device is not intended for post-dilatation of deployed transcatheter heart valves. While exposed within the body, device advancement and retrieval should not be done without the aid of fluoroscopy. Do not advance or retract the device unless the balloon is fully deflated under vacuum. Potential Adverse Events: Complications associated with standard catheterization, balloon valvuloplasty, and the use of angiography include, but are not limited to, allergic reaction to anesthesia or to contrast media, injury including perforation or dissection of vessels, thrombus formation, plaque dislodgement and embolization that may result in myocardial infarction, stroke, distal peripheral occlusion and/or death, arrhythmia development, cardiac perforation, conduction system injury, hematoma, infundibulum injury, annular tear or rupture and/or valve leaflet dehiscence, severe valve insufficiency, valve restenosis, valve damage, balloon rupture, balloon separation following balloon rupture, valvular tearing or trauma, thromboembolic events, and infection. Reference the Edwards SAPIEN XT Transcatheter Heart Valve with the NovaFlex+ Delivery System Instructions for Use for a full list of potential adverse events. EDWARDS EXPANDABLE INTRODUCER SHEATH SET Indications: The Edwards expandable introducer sheath is indicated for the introduction and removal of devices used with the Edwards SAPIEN XT Transcatheter Heart Valve. Contraindications: This product is contraindicated for tortuous or calcified vessels that would prevent safe entry of the introducer and sheath. Warnings: The devices are designed, intended, and distributed for single use only. Do not resterilize or reuse the devices. There is no data to support the sterility, nonpyrogenicity, and functionality of the devices after reprocessing. The Edwards Expandable Introducer Sheath Set must be used with a compatible guidewire. Precautions: Do not use the introducer sheath set if the packaging sterile barriers and any components have been opened or damaged. The Edwards Expandable Sheath temporarily enlarges to allow the passage of devices; ensure that the vasculature can accommodate the maximum diameter of the expanded sheath. When inserting, manipulating or withdrawing a device through the expandable sheath, always maintain sheath position. When puncturing, suturing or incising the tissue near the sheath, use caution to avoid damage to the sheath. Potential Adverse Events: Complications associated with standard catheterization and use of angiography include, but are not limited to, injury including perforation or dissection of vessels, thrombosis, and/or plaque dislodgement which may result in emboli formation, distal vessel obstruction, stroke, infection, and/or death.

22 IMPORTANT RISK INFORMATION EDWARDS SAPIEN XT TRANSCATHETER HEART VALVE WITH THE ASCENDRA+ DELIVERY SYSTEM Indications: The Edwards SAPIEN XT Transcatheter Heart Valve, model 9300TFX, systems are indicated for relief of aortic stenosis in patients with symptomatic heart disease due to severe native calcific aortic stenosis (aortic valve area 1.0 cm 2 or aortic valve area index 0.6 cm 2 /m 2, a mean aortic valve gradient of 40 mmhg, or a peak aortic-jet velocity of 4.0 m/s), and with native anatomy appropriate for the 23, 26, or 29 mm valve system, who are judged by a heart team, including a cardiac surgeon, to be at high or greater risk for open surgical therapy (i.e., Society of Thoracic Surgeons operative risk score 8% or at a 15% risk of mortality at 30 days). Contraindications: The THV and delivery systems are contraindicated in patients who cannot tolerate an anticoagulation/antiplatelet regimen or who have active bacterial endocarditis or other active infections. Warnings: Observation of the pacing lead throughout the procedure is essential to avoid the potential risk of pacing lead perforation. There is an increased risk of stroke in transcatheter aortic valve replacement procedures, as compared to balloon aortic valvuloplasty or other standard treatments. The devices are designed, intended, and distributed for single use only. Do not resterilize or reuse the devices. There are no data to support the sterility, nonpyrogenicity, and functionality of the devices after reprocessing. Incorrect sizing of the THV may lead to paravalvular leak, migration, embolization and/or annular rupture. Accelerated deterioration of the THV may occur in patients with an altered calcium metabolism. Prior to delivery, the THV must remain hydrated at all times and cannot be exposed to solutions other than its shipping storage solution and sterile physiologic rinsing solution. THV leaflets mishandled or damaged during any part of the procedure will require replacement of the THV. Caution should be exercised in implanting a THV in patients with clinically significant coronary artery disease. Patients with preexisting mitral valve devices should be carefully assessed prior to implantation of the THV to ensure proper THV positioning and deployment. Patients presenting with combination AV low flow, low gradient should undergo additional evaluation to establish the degree of aortic stenosis. Do not use the THV if the tamper evident seal is broken, the storage solution does not completely cover the THV, the temperature indicator has been activated, the THV is damaged, or the expiration date has elapsed. Do not mishandle the Ascendra+ delivery system or use it if the packaging or any components are not sterile, have been opened or are damaged (e.g. kinked or stretched), or the expiration date has elapsed. Care should be exercised in patients with hypersensitivities to cobalt, nickel, chromium, molybdenum, titanium, manganese, silicon, and/or polymeric materials. The procedure should be conducted under fluoroscopic guidance. Some fluoroscopically guided procedures are associated with a risk of radiation injury to the skin. These injuries may be painful, disfiguring, and long-lasting. THV recipients should be maintained on anticoagulant/antiplatelet therapy, except when contraindicated, as determined by their physician. This device has not been tested for use without anticoagulation. Do not add or apply antibiotics to the storage solution, rinse solutions, or to the THV. Precautions: Long-term durability has not been established for the THV. Regular medical follow-up is advised to evaluate THV performance. Glutaraldehyde may cause irritation of the skin, eyes, nose and throat. Avoid prolonged or repeated exposure to, or breathing of, the solution. Use only with adequate ventilation. If skin contact occurs, immediately flush the affected area with water; in the event of contact with eyes, seek immediate medical attention. For more information about glutaraldehyde exposure, refer to the Material Safety Data Sheet available from Edwards Lifesciences. To maintain proper valve leaflet coaptation, do not overinflate the deployment balloon. Appropriate antibiotic prophylaxis is recommended post-procedure in patients at risk for prosthetic valve infection and endocarditis. Safety, effectiveness, and durability have not been established for valve-invalve procedures. Safety and effectiveness have not been established for patients with the following characteristics/comorbidities: Non-calcified aortic annulus, severe ventricular dysfunction with ejection fraction < 20%, congenital unicuspid or congenital bicuspid aortic valve, mixed aortic valve disease (aortic stenosis and aortic regurgitation with predominant aortic regurgitation > 3+), pre-existing prosthetic heart valve or prosthetic ring in any position, severe mitral annular calcification (MAC), severe (> 3+) mitral insufficiency, or Gorlin syndrome, blood dyscrasias defined as: leukopenia (WBC < 3000 cells/ml), acute anemia (Hb < 9 g/dl), thrombocytopenia (platelet count <50,000 cells/ml) or history of bleeding diathesis or coagulopathy, hypertrophic cardiomyopathy with or without obstruction (HOCM), echocardiographic evidence of intracardiac mass, thrombus, or vegetation, a known hypersensitivity or contraindication to aspirin, heparin, ticlopidine (Ticlid ), or clopidogrel (Plavix ), or sensitivity to contrast media, which cannot be adequately premedicated, excessive calcification of vessel at access site, bulky calcified aortic valve leaflets in close proximity to coronary ostia. Potential Adverse Events: Potential risks associated with the overall procedure including potential access complications associated with standard cardiac catheterization, balloon valvuloplasty, the potential risks of conscious sedation and/or general anesthesia, and the use of angiography: death; stroke/transient ischemic attack, clusters or neurological deficit; paralysis; permanent disability; respiratory insufficiency or respiratory failure; hemorrhage requiring transfusion or intervention; cardiovascular injury including perforation or dissection of vessels, ventricle, myocardium or valvular structures that may require intervention; pericardial effusion or cardiac tamponade; embolization including air, calcific valve material or thrombus; infection including septicemia and endocarditis; heart failure; myocardial infarction; renal insufficiency or renal failure; conduction system defect which may require a permanent pacemaker; arrhythmia; retroperitoneal bleed; AV fistula or pseudoaneurysm; reoperation; ischemia or nerve injury; restenosis; pulmonary edema; pleural effusion; bleeding; anemia; abnormal lab values (including electrolyte imbalance); hypertension or hypotension; allergic reaction to anesthesia, contrast media, or device materials; hematoma; syncope; pain or changes at the access site; exercise intolerance or weakness; inflammation; angina; heart murmur; fever. Additional potential risks associated with the use of the THV, delivery system, and/or accessories include: cardiac arrest; cardiogenic shock; emergency cardiac surgery; cardiac failure or low cardiac output; coronary flow obstruction/transvalvular flow disturbance; device thrombosis requiring intervention; valve thrombosis; device embolization; device migration or malposition requiring intervention; valve deployment in unintended location; valve stenosis; structural valve deterioration (wear, fracture, calcification, leaflet tear/tearing from the stent posts, leaflet retraction, suture line disruption of components of a prosthetic valve, thickening, stenosis); device degeneration; paravalvular or transvalvular leak; valve regurgitation; hemolysis; device explants; nonstructural dysfunction; mechanical failure of delivery system, and/or accessories; non-emergent reoperation. ASCENDRA BALLOON AORTIC VALVULOPLASTY CATHETER Indications: The Ascendra Balloon Aortic Valvuloplasty Catheter is indicated for valvuloplasty of a stenotic aortic valve prior to implantation of the Edwards SAPIEN or Edwards SAPIEN XT Transcatheter Heart Valve. Contraindications: Other than standard risks associated with insertion of a cardiovascular catheter, there are no known contraindications for valvuloplasty. The patient s medical condition could affect successful use of this catheter. Warnings: The device is designed, intended, and distributed for single use only. Do not resterilize or reuse the device. There are no data to support the sterility, nonpyrogenicity, and functionality of the device after reprocessing. Do not mishandle the device or use it if the packaging or any components are not sterile, have been opened or are damaged (e.g. kinked or stretched), or the expiration date has elapsed. Precautions: For special considerations associated with the use of this device prior to transcatheter heart valve (THV) implantation, refer to the THV instructions for use (IFU). This catheter has not been tested with any transcatheter valve other than the Edwards SAPIEN and Edwards SAPIEN XT transcatheter heart valve. Use only appropriate balloon inflation medium. Do not use air or gaseous medium to inflate the balloon. The device is not intended for post-dilation of deployed transcatheter heart valves. While exposed within the body, device advancement and retrieval should not be done without the aid of fluoroscopy. Do not advance or retract the device unless the balloon is fully deflated under vacuum. Potential Adverse Events: Complications associated with standard catheterization, balloon valvuloplasty, and the use of angiography include, but are not limited to, allergic reaction to anesthesia or to contrast media, thrombus formation, plaque dislodgement and embolization that may result in myocardial infarction, stroke, distal peripheral occlusion and/or death, arrhythmia development, cardiac perforation, conduction system injury, hematoma, infundibulum injury, annular tear or rupture and/or valve leaflet dehiscence, severe valve insufficiency, valve restenosis, valve damage, balloon rupture, balloon separation following balloon rupture, valvular tearing or trauma, thromboembolic events, and infection. Reference the Edwards SAPIEN Transcatheter Heart Valve with the Ascendra Balloon Catheter, Edwards SAPIEN Transcatheter Heart Valve with the Ascendra 3 Delivery System, or the Edwards SAPIEN XT Transcatheter Heart Valve with the Ascendra+ Delivery System Instructions for Use for a full list of potential adverse events. ASCENDRA+ INTRODUCER SHEATH SET Indications: The Ascendra+ Introducer Sheath Set is indicated for the introduction and removal of devices used with the Edwards SAPIEN XT Transcatheter Heart Valve. Contraindications: No known contraindications. Warnings: The devices are designed, intended, and distributed for single use only. Do not resterilize or reuse the devices. There are no data to support the sterility, nonpyrogenicity, and functionality of the devices after reprocessing. Do not mishandle the device or use it if the packaging or any components are not sterile, have been opened or are damaged (e.g. kinked or stretched), or the expiration date has elapsed. Should not be used in patients with left ventricular aneurysm. The Ascendra+ Introducer Sheath Set must be used with a guidewire. Precautions: No known precautions. Potential Adverse Events: Complications associated with cardiac surgical intervention and use of angiography include, but are not limited to, allergic reaction to anesthesia or to contrast media, injury including myocardial injury, thrombus formation, and plaque dislodgement which may result in myocardial infarction, arrhythmia, stroke, and/or death. Reference the Edwards SAPIEN XT Transcatheter Heart Valve with the Ascendra+ Delivery System Instructions for Use for a full list of potential adverse events. EDWARDS CRIMPER Indications: The Edwards Crimper is indicated for use in preparing the Edwards SAPIEN XT Transcatheter Heart Valve for implantation. Contraindications: No known contraindications. Warnings: The device is designed, intended, and distributed for single use only. Do not resterilize or reuse the device. There are no data to support the sterility, nonpyrogenicity, and functionality of the device after reprocessing. Do not mishandle the device. Do not use the device if the packaging or any components are not sterile, have been opened or are damaged, or the expiration date has elapsed. Precautions: For special considerations associated with the use of this device prior to THV implantation, refer to the SAPIEN XT Transcatheter Heart Valve Instructions for Use. Potential Adverse Events: No known potential adverse events. CAUTION: Federal (United States) law restricts these devices to sale by or on the order of a physician. See instructions for use for full prescribing information, including indications, contraindications, warnings, precautions and adverse events. Edwards, Edwards Lifesciences, the stylized E logo, Ascendra, Ascendra 3, Ascendra+, Edwards SAPIEN, Edwards SAPIEN XT, NovaFlex, NovaFlex+, RetroFlex, RetroFlex 3, SAPIEN and SAPIEN XT are trademarks of Edwards Lifesciences Corporation Edwards Lifesciences Corporation. All rights reserved. AR11592 Edwards Lifesciences I edwards.com Irvine, California USA

Important Safety Information

Important Safety Information Edwards SAPIEN 3 Transcatheter Heart Valve with the Edwards Commander Delivery System Indications: The Edwards SAPIEN 3 transcatheter heart valve, model 9600TFX, and the Society