Abbott Navitor Titan Transcatheter Aortic Valve Implantation System Instructions

Navitor Titan Transcatheter Aortic Valve Implantation System
Instruction Manual

Navitor Titan Transcatheter Aortic Valve Implantation System

Navitor Titan™ Transcatheter Aortic Valve Implantation System
Navitor Titan™ Transcatheter Aortic Valve
FlexNav™ Delivery System
Navitor™ Loading System – LG+
PRT-NG-35
FN-DS-LG-IDE/FNAV-DS-LG
PRT-NG-LS-35
Instructions for Use
™ Indicates a trademark of the Abbott group of companies.
‡ Indicates a third-party trademark, which is the property of its respective owner.
Pat. http://www.abbott.com/patents
© 2021 Abbott. All Rights Reserved.
Navitor™
Transcatheter Aortic Valve Implantation System
Instructions for Use
CAUTION: Investigational Device. Limited by Federal (USA) law to investigational use.
CAUTION: Exclusively for Clinical Investigation Use.
CAUTION: The Navitor Titan™ Transcatheter Aortic Valve Implantation System should only be used by physicians who have undergone training on the use of this system.

Description

Navitor™ Transcatheter Aortic Valve Implantation System
The Navitor Titan™ Transcatheter Aortic Valve Implantation System (hereafter described as the implantation system) consists of the Navitor Titan™ transcatheter aortic valve,  the FlexNav™ delivery system, and the Navitor™ loading system – LG+, as described below.
Table 1. Navitor Titan™ Implantation System Components

Navitor Titan™ Valve Catalog Number| FlexNav™ Delivery System Catalog
Number| Navitor™ Loading System – LG+
Catalog Number
---|---|---
PRT-NG-35 (35 mm)| FN-DS-LG-IDE/FNAV-DS-LG| PRT-NG-LS-35

Navitor™ Valve

The Navitor Titan™ valve is designed to be implanted in the native calcific aortic heart valve without open heart surgery and without concomitant surgical removal of the failed native valve.

Figure 1. Navitor Titan™ valve

The valve is comprised of three main components: stent, cuff, and leaflets. The stent is made from nitinol, a nickel-titanium alloy that has self- expanding properties and is radiopaque. The cuff consists of an inner and outer portion which is made from polyethylene. The cuff provides the sealing area for implantation and provides paravalvular leak reduction by filling any potential voids between the native valve and the stent. The leaflets are made from the bovine pericardium and are sutured together into a tri-leaflet configuration on the stent frame.
The leaflet pericardial tissue is preserved and crosslinked in glutaraldehyde. Glutaraldehyde, formaldehyde, and ethanol are used in the valve sterilization process.
The valve leaflets are processed using Linx™ anti calcification technology. The valve is supplied sterile and non-pyrogenic.
Evaluate the patient’s cardiac anatomy for the characteristics described in the following table.

Patient Anatomical Evaluation

Table 2. Patient Anatomical Specifications

Catalog Number| Annulus Diameter| Ascending Aorta Diameter Area1| Perimeter2| Eccentricity Ratio (minor/major dia ratio)
---|---|---|---|---

¹Area and perimeter specifications are for reference only.
²Area and perimeter specifications are for reference only.

Catalog Number| Annulus Diameter| Ascending Aorta Diameter| Area1| Perimeter2| Eccentricity Ratio (minor/major dia ratio)
---|---|---|---|---|---
PRT-NG-35| 27-30 mm| 27-44 mm| 559-707 mm2| 85-95 mm| ≥ 0.73

FlexNav™ Delivery System

The FlexNav™ delivery system facilitates Navitor Titan™ valve implantation using transfemoral, subclavian or axillary access methods.
The delivery system may be inserted into the vessel via its integrated sheath or through a separate arterial introducer sheath.
The delivery system design facilitates gradual, controlled deployment of the valve. The valve is deployed annulus end first from the distal end of the delivery system. If needed,  the valve may be re-sheathed and repositioned up to two times, provided the valve has not been fully deployed.
Table 3. FlexNav™ Delivery System Specifications

Delivery System
Catalog Number| Equivalent
Integrated
Sheath Diameter| Valve Capsule
Outer
Diameter| Integrated
Sheath Working
Length| Delivery System
Length| Minimum Vessel
Diameter
Requirement| Compatible Guidewire
---|---|---|---|---|---|---
FN-DS-LGIDE/FNAV-DSLG| 15F| 6.3 mm| 30 cm| 107 cm| ≥ 5.5 mm| 0.035″ (0.89 mm)

The delivery system is compatible with 19F (FN-DS-LG-IDE/FNAV-DS-LG) introducer sheaths.
The distal end features:
A valve capsule covers and maintains the valve in the collapsed position within the delivery system. The valve capsule may be advanced or retracted to facilitate valve loading and deployment. The valve capsule features a radiopaque valve capsule marker band that provides a reference point used to determine the extent of the valve deployment.  When the valve capsule is retracted the inner shaft is exposed.
The valve is loaded onto the inner shaft. Retainer tabs on the valve lock into a retainer receptacle that is mounted on the inner shaft. A radiopaque inner shaft marker band provides a reference point used to initially align the valve in the native annulus.
An atraumatic radiopaque tip is used to guide the delivery system and facilitate visualization.
This device is coated with a hydrophilic coating in the following locations:

• The radiopaque tip and valve capsule are coated over their entire surfaces
• The integrated sheath is coated from the distal end to within 5 cm of the integrated sheath hub

WARNINGS:

• Avoid wiping the device with dry gauze as this may damage the device coating.
• Avoid excessive wiping of the coated device.
• Avoid using alcohol, antiseptic solutions, or other solvents to pre-treat the device because this may cause unpredictable changes in the coating which could affect the device safety and performance.
• Avoid pre-soaking devices for longer than instructed, as this may impact the coating performance.

Please refer to Loading the Valve on the Delivery System (page 8) for further information on how to prepare and use this device to ensure it performs as intended. Failure to  abide by the warnings in this labeling might result in damage to the device coating, which may necessitate intervention or result in serious adverse events.

Figure 2. The distal end of the delivery system

The proximal end features:

• Two macro slide buttons facilitate the opening and closure of the distal end of the delivery system.
• A deployment/re-sheath wheel is used to adjust the position of the valve capsule during valve loading and deployment.
• A micro-adjustment wheel is used to close gaps between the valve capsule and the radiopaque tip.
• A deployment indicator provides visualization of the extent of valve deployment.
• A deployment lock button prevents full valve deployment before the valve position is optimized. The valve may be re-captured when the deployment indicator is in the white zone; the valve may not be recaptured when the deployment indicator is in the gray zone.
• Flush ports facilitate de-airing of the system.
• An integrated sheath facilitates vascular access, minimizing access site size to the capsule diameter.
• A stability layer facilitates stable delivery system retraction by allowing the distal end of the delivery system to move freely within the integrated sheath.

Figure 3. Delivery system handle

Navitor™ Loading System – LG+

The Navitor™ loading system – LG+ facilitates valve preparation/loading onto the FlexNav™ delivery system. The loading system configuration includes a loading funnel,  loading base, two base inserts (not used with Navitor™ Titan valve), loading tube, stent guide, and leaflet tester.
Figure 4. PRT-NG-LS-35 Loading system

Indications

The Navitor Titan™ valve is indicated for transcatheter delivery in patients with symptomatic severe native aortic stenosis who are considered a high or extreme surgical risk.
The FlexNav™ delivery system is indicated for transfemoral or subclavian/axillary delivery of the Navitor Titan™ valve.
The Navitor™ loading system – LG+ is indicated for loading the Navitor Titan™ valve in the FlexNav™ delivery system.

Contraindications

The valve is contraindicated for patients with:

• Any sepsis, including active endocarditis.
• Any evidence of left ventricular or atrial thrombus.
• Vascular conditions (i.e., stenosis, tortuosity, or severe calcification) that make insertion and endovascular access to the aortic valve impossible.
• Non-calcified aortic annulus.
• Any leaflet configuration is other than tricuspid.
• Inability to tolerate antiplatelet/anticoagulant therapy.

Warnings

• Perform Navitor Valve™ valve implantation in a facility where emergency aortic valve surgery is available.
• Verify that the patient’s cardiac anatomy is consistent with the specifications set forth in the anatomical specifications table.
• For single use only. Do not reuse, reprocess, or resterilize the valve, delivery system, or loading system. Reuse, reprocessing, and/or resterilization creates a risk of contamination of the devices and/or device failure, which could cause patient injury, illness, or death.
• Do not manipulate or handle the valve with sharp or pointed objects.
• Rinse the valve as directed before loading the valve onto the delivery system.
• Do not use the valve, the delivery system, or the loading system if the “USE BY” date has elapsed.
• Exercise care to prevent kinking of the delivery system when removing it from the packaging.

Precautions

Pre-Implantation Precautions

• For subclavian/axillary access, use caution in patients with mammary artery grafts.
• Balloon aortic valvuloplasty (BAV) of the native aortic valve is recommended prior to delivery system insertion. The balloon size chosen should be appropriate, not exceeding the minimum diameter of the native aortic annulus as assessed by CT imaging to minimize the risk of annular rupture and not undersized to minimize risk of stent under-expansion which could lead to paravalvular leak (PVL) or device migration.
• Do not use the valve if the shipping temperature indicator on the product package has turned red, or if the valve has been improperly stored in temperature conditions outside of the 5°C–25°C (41°F–77°F) range.
• Do not use the valve if the tamper-evident container seal is damaged, broken, or missing, or if fluid is leaking from the packaging.
• Do not advance the delivery system without the guidewire extending from the tip.
• Do not use the valve without thoroughly rinsing as directed.
• Do not use the delivery system without thoroughly flushing as described in the “Directions for Use” section.
  Safety and effectiveness have not been established for patients with the following characteristics:
  – Sinus of Valsalva anatomy that would prevent adequate coronary perfusion
  – Bulky calcified aortic valve leaflets in close proximity to coronary Ostia

Implantation Precautions

• A manufacturer’s pre-shaped guidewire should be used during the procedure and valve deployment to minimize the risk of the guidewire perforations in the left ventricle.
• Do not deploy the valve if excessive resistance to deployment is encountered. If the valve does not deploy easily, re-sheathe the valve, remove it from the patient, and use a different valve and delivery system.
• Follow the procedure in “Implanting the Valve” to reposition the valve or to remove the valve from the patient.
• Do not attempt to reposition the valve by advancing it distally unless the valve has been fully re-sheathed within the delivery system.
• Do not re-sheathe the valve more than two times prior to final valve release. Additional re-sheath attempts may compromise product performance.
• To minimize the likelihood of permanent pacemaker implantation (PPI): a) maintain implant depth of 3mm, and b) limit manipulations across the LVOT.

Post-Implantation Precautions

• In the event that a post-implant balloon dilatation is performed to address paravalvular leak (PVL), valve size, patient anatomy, and implant depth must be considered when  selecting the size of the balloon for dilatation. The balloon size chosen should not exceed the mean diameter of the native aortic annulus. Moderate or Severe PVL  should be addressed at the time of the TAVR procedure.
• Exercise care when removing the delivery system from the patient.
• Exercise care when crossing the valve with adjunctive devices.
• Once the valve is fully deployed, repositioning and retrieval of the valve is not possible. Attempted retrieval (e.g., use of a guidewire, snare, or forceps) may cause aortic  root, coronary artery, and/or myocardial damage.
• Valve recipients should be maintained on antiplatelet and/or anticoagulant therapy post-procedure, per institutional standards and established guidelines, except when contraindicated, using individualized treatment as determined by their physician.
• Post-implant monitoring and/or possible electrophysiology evaluation may be considered in patients with a transient high degree or complete AV block or other conduction disturbances during or following implantation of the valve. This may include continuous ECG monitoring after hospital discharge.

Magnetic Resonance (MR) Safety Information

Non-clinical testing has demonstrated that the Navitor Titan™ valve is MR Conditional. A patient with the Navitor Titan™ valve can be safely scanned in an MR system under  the following conditions:

• The static magnetic field of 1.5 Tesla (1.5T) or 3.0-Tesla (3.0T).
• Maximum spatial gradient field of 19 T/m (1900 G/cm).
• Maximum MR system reported, a whole-body averaged specific absorption rate (SAR) of 2.0 W/kg (normal operating mode)

Under the scan conditions defined above, the device is expected to produce a maximum temperature rise of less than or equal to 3ºC after 15 minutes of continuous scanning In non-clinical testing, the image artifact caused by the device extends radially up to 0.5 cm from the device when imaged with a gradient echo pulse sequence in a 1.5T MR system.

Potential Adverse Events

Adverse events potentially associated with the use of transcatheter bioprosthetic heart valves include but are not limited to:

• access site complications (e.g., pain, bleeding, infection, hematoma, pseudoaneurysm, etc.)
• acute coronary obstruction
• acute myocardial infarction
• allergic reaction to antiplatelet agents, contrast medium, or valve components
• aortic rupture
• ascending aorta trauma
• atrioventricular node block
• cardiac arrhythmias
• conduction system injury
• dissection
• embolism
• endocarditis
• heart failure
• hemodynamic compromise
• hemolysis
• hemolytic anemia
• hemorrhage (bleeding)
• hypotension or hypertension
• infection
• myocardial ischemia
• mitral valve insufficiency
• multi-organ failure
• non-structural dysfunction (i.e., entrapment by pannus, paravalvular leak, inappropriate sizing or positioning)
• pericardial effusion
• perforation of the myocardium or a blood vessel
• pannus
• regurgitation
• renal insufficiency or renal failure (acute kidney injury)
• respiratory failure
• sepsis
• stroke
• structural deterioration (i.e., calcification, leaflet tear)
• thrombosis
• tamponade
• valve embolization or migration
• vessel dissection or spasm.

It is possible these complications could lead to:

• transfusion
• conversion to open surgical procedure
• reoperation
• emergent balloon valvuloplasty
• emergent percutaneous coronary intervention (PCI)
• emergent surgery (i.e., coronary artery bypass, heart valve replacement)
• explantation
• permanent disability
• death
• permanent pacemaker

Materials and Equipment
The following materials and equipment are required for the implantation of the Navitor Titan™ valve:

• standard cardiac catheterization lab equipment
• fluoroscopy equipment appropriate for use in percutaneous coronary interventions
• transesophageal or transthoracic echocardiographic equipment
• sterile isotonic saline
• 20 cc Luer-lock syringe
• balloon catheter
• exchange length 0.035” (0.89 mm) x 260 cm manufacturer pre-shaped super stiff or equivalent manufacturer pre-shaped guidewire
• three sterile 500 mL basins
• sterile gauze pads

Packaging and Storage

Valve
The valve is supplied in a jar containing formaldehyde storage solution. The jar has a screw cap closure and tamper-evident seal. The valve is supplied on a disposable holder.  The contents of the jar are sterile and must be handled aseptically to prevent contamination.
Store the valve in the upright position.
CAUTION: Do not use the valve without thoroughly rinsing as directed.
CAUTION: Do not use the valve if the shipping temperature indicator on the product package has turned red, or if the valve has been improperly stored in temperature  conditions outside of the 5°C–25°C (41°F–77°F) range.

Delivery System/Loading System
The delivery system and loading system are sterilized with ethylene oxide gas. The delivery system is supplied in a tray within an outer pouch.
The loading system is supplied in a double-barrier tray. The inner delivery system/loading system trays are supplied sterile provided the outer pouch/tray packaging is not opened or damaged.

Directions for Use
Use standard imaging techniques (including computed tomography [CT] and/or echocardiography) to determine aortic annulus diameter.
Pre-Implant Handling
Do not open the valve package until implantation and sizing are certain.
Warnings:

• Do not use the valve, delivery system, or loading system if the “USE BY” date has elapsed or if the integrity of the sterile packaging has been compromised.
• Do not use the valve if fluid is leaking from the packaging.
• Do not resterilize the valve, delivery system, or loading system by any method.
• Do not use the valve, the delivery system, or the loading system if it has been dropped, damaged or mishandled in any way.

Removing the Valve from the Packaging
PRECAUTIONS:

• Do not place the non-sterile exterior of the valve container in the sterile field.
• Do not expose the valve to solutions other than the formaldehyde solution in which it was shipped, the sterile isotonic saline solution used during the rinsing procedure, or  the sterile isotonic saline used to irrigate the valve.
• Do not add antibiotics to either the formaldehyde storage solution or the rinse solution.
• Do not apply antibiotics to the valve.

Once the valve container has been removed from the outer packaging, examine the container for evidence of damage.
CAUTION: Do not use the valve if the tamper-evident jar seal is damaged, broken, or missing, or if fluid is leaking from the packaging.
WARNING: Do not use the valve if it is not completely covered by formaldehyde storage solution.
Prior to use, verify the valve size and “USE BY” date on the packaging label and the jar label.
To remove the valve from the jar, break the seal and remove the screw-top closure.
CAUTION: Avoid prolonged contact with the formaldehyde storage solution. Immediately after contact, thoroughly flush any skin exposed to the solution with water. In case  of contact with eyes, flush with water and seek appropriate medical care.
Using sterile forceps or gloved hands, carefully grasp the valve holder and remove the valve from the jar. Drain the valve completely.
CAUTION: Do not handle the valve or leaflet tissue with unprotected forceps or sharp instruments.
Remove the valve from the valve holder by carefully compressing the aortic end of the valve stent circumferentially. Take care not to touch the valve tissue.
Inspect the valve for damage. Do not use the valve if there is any sign of damage or deterioration.

Rinsing the Valve
CAUTION: Do not use the valve without thoroughly rinsing as directed.
CAUTION: Do not allow the tissue to dry. Place the valve in sterile isotonic saline rinse solution immediately upon removal from the formaldehyde storage solution.
Within the sterile field, prepare three sterile basins with a minimum of 500 mL of sterile isotonic saline in each basin. Saline in the first two basins will be used for valve rinsing.  Saline in the third basin will be used for delivery system preparation.
CAUTION: Do not use saline from the first or second basins for delivery system preparation.
NOTE: Chilled saline is not required.
Fully immerse the valve in the sterile isotonic saline solution in the first basin.
Continually rinse the valve for 10 seconds, using a gentle back-and-forth motion.
Repeat steps 2 and 3 in the second basin.
After rinsing, leave the valve fully immersed in the second basin until it is ready to be loaded.

Compressing the Valve in the Loading System

CAUTION: Do not place the non-sterile packaging of the loading system in the sterile field.
Perform the following steps in the sterile field, at room temperature:

1. Insert the Stent guide through the center of the loading base.
   NOTE: Do not use a base insert.
   

2. Place the annulus end of the valve in the loading base.

3. Wet the loading funnel in sterile isotonic saline.

4. Place the wide end of the loading funnel directly over the aortic end of the valve.

5. Gently push straight down on the loading funnel to compress the valve. Align the loading funnel slots with the tabs on the loading base. Rotate the loading funnel slightly clockwise until it locks into the loading base. The aortic end of the valve will protrude out of the loading system assembly.

6. Remove the stent guide.

Loading the Valve on the Delivery System

Load the valve on the delivery system in the sterile field, at room temperature, under direct visualization.
CAUTION: Do not use the delivery system if it is kinked or damaged.
CAUTION: Do not place the non-sterile packaging of the delivery system in the sterile field.
NOTE: The valve must be loaded onto the delivery system by trained personnel.

1. Wet a sterile gauze pad with sterile isotonic saline and wipe the shaft of the delivery system.

2. Wet the loading tube in sterile isotonic saline.

3. Slide the loading tube over the valve capsule of the delivery system. Position the distal end of the loading tube below the distal tip of the valve capsule.

4. Open the delivery system by closing the macro slide. Ensure the slide is locked in the closed position.

5. Fill a 20 cc syringe with sterile isotonic saline.
   NOTE: Use of a syringe size greater than 20 cc may result in inadequate de-airing.

6. Holding the distal tip of the delivery system upright, de-air the system by injecting a minimum of 15-20 cc saline into the valve capsule flush port. Tap the loading tube to dislodge any air bubbles while completing the flush.
   NOTE: Keep the distal end of the delivery system upright until the valve is completely encased in the valve capsule.

7. Remove the syringe.

8. To facilitate passage of the valve over the radiopaque tip of the delivery system, compress the loading funnel and loading base to slightly open the aortic end of the valve, as shown.
   Figure 6. Slightly open the aortic end of the valve

9. Carefully thread the radiopaque tip of the delivery system through the loading funnel and loading base assembly. When the radiopaque tip is just past the stent retainer tabs,  slightly release the compression of the loading funnel while continuing to advance the radiopaque tip as it passes through the narrow end of the loading funnel. Guide the  three (valve) retainer tabs into the (delivery system) retainer receptacles.
   CAUTION: Carefully insert the radiopaque tip of the delivery system through the center of the loading base to avoid damage to the delivery system.

10. Engage the three retainer tabs with the retainer receptacle by slightly opening the aortic end of the valve (see step 8 of this section).
    Visually confirm that all three retainer tabs are engaged and that no stent struts are overlapping. The ends of the stent struts without retainer tabs should be aligned with,  but not overlapping, the proximal end of the retainer receptacle, as shown.
    CAUTION: Do not use the valve if the retainer tabs are bent or deformed. Ensure no stent struts are crossed or misaligned.

11. Slowly encapsulate the retainer tabs in the valve capsule, by turning the deployment/re-sheath wheel opposite the direction of the arrow on the handle until the maximum outer diameter (OD) of the strain relief is aligned with the distal end of the valve capsule, as shown below.
    Caution: Ensure the retainer tabs remain engaged in the retainer receptacles and ensure the valve does not tilt or lean during the advancement of the valve capsule.
    Figure 8. Encapsulate the retainer tabs (shown without valve for clarity)
    1. Strain relief
    2. Maximum outer diameter

12. Advance the loading tube to meet the narrow end of the loading funnel. Align the black indicator line on the loading tube with the distal end of the valve capsule.

13. Turn the deployment/re-sheath wheel opposite the direction of the arrow on the handle until the funnel is fully seated in the loading tube.

14. Unlock and remove the loading base from the loading funnel.

15. Pour sufficient saline into the loading funnel to cover the valve.

16. Tap the radiopaque tip of the delivery system to remove any air bubbles from the inner shaft.

17. Remove any remaining air bubbles by gently sliding the leaflet tester from the top to the bottom of each leaflet.
    CAUTION: Exercise care to avoid damaging the leaflets with the leaflet tester.

18. Inspect the valve to ensure that no leaflet tissue is trapped between the stent struts. If leaflet tissue is trapped between the stent struts, use the narrow end of the leaflet  tester to move the leaflets inside of the stent.

19. Grasp the shaft of the delivery system just below the loading tube while encapsulating the valve. Turn the deployment/re-sheath wheel opposite the direction of the arrow  on the handle until the valve is fully encased in the valve capsule.
    NOTE: Ensure the distal end of the valve capsule remains below the black indicator line on the loading tube.
    CAUTION: Do not use the device if excess force is required to turn the deployment/re-sheath wheel during encapsulation.
    CAUTION: Do not re-sheathe the valve more than two times prior to final valve release. Additional re-sheath attempts may compromise product performance.

20. If necessary, turn the micro adjustment wheel in the direction of the arrow to close any gaps between the valve capsule and the radiopaque tip. Once the gap is closed, turn the micro adjustment wheel opposite the direction arrow, until the wheel stops.

21. Pour the saline out of the loading funnel.

22. Slide the loading funnel and loading tube of the distal end of the delivery system.
    CAUTION: Inspect the valve capsule to ensure loading was successful. The surface should be smooth and free from ridges or creases. If a device is found to be incorrectly  loaded, replace the valve and delivery system with new components.

23. Fill the syringe with sterile isotonic saline, and complete system de-airing as described below:
    a. Flush the stability layer.
    b. Slide the integrated sheath tip off the stability layer.
    c. Flush the integrated sheath.
    d. Close the stopcock on the integrated sheath.
    e. Slide the integrated sheath up to the valve capsule.
    f. Engage the integrated sheath tip onto the valve capsule.
    g. Flush the guidewire lumen.

Implanting the Valve

• Prepare the access site according to standard practice.
  CAUTION: If performing transcatheter valve implantation without an arterial introducer sheath, use a minimum 14F introducer sheath for balloon aortic valvuloplasty.

CAUTION: For subclavian/axillary procedures, the distance between the annular plane and the integrated sheath distal tip must be ≥ 17 cm (6.7″) to allow the valve capsule to  retract completely during valve deployment.

1. Predilate the native aortic valve with an appropriate diameter valvuloplasty balloon.

Deploying the Valve

1. Backload the FlexNav™ delivery system onto an 0.035″ (0.89 mm)-compatible manufacturer pre-shaped guidewire while maintaining position across the aortic valve. NOTE: Wipe the radiopaque tip, valve capsule, and integrated sheath with a wet gauze pad to activate the hydrophilic coating.

2. Advance the distal end of the delivery system through the access site until the integrated sheath hub meets the access site. If using the integrated sheath, be sure to hold on  to both the integrated sheath and the delivery system shaft, keeping them joined together upon insertion.
   NOTE: It is recommended to rotate the delivery system and integrate the sheath back and forth during insertion into the artery.

3. Position the delivery system so that the inner shaft marker band is aligned with the native aortic valve annulus plane.

4. Begin deploying the valve by turning the deployment/re-sheath wheel in the direction of the arrow on the handle. Maintain valve position during deployment to ensure accuracy of implant depth.
   NOTE: Position the leading inflow edge of the valve 3 mm (0.12″) below the native aortic annulus.

5. Prior to release, position the fluoro source to ensure the struts at the ventricular end of the nitinol stent are aligned and confirm the depth of the implant is approximately 3mm.
   NOTE: The deployment/re-sheath wheel will make a clicking sound when it has reached the partial deployment lock, and the deployment mechanism will not engage until the deployment lock button is depressed.
   CAUTION: Do not depress the deployment lock button until you are ready to fully deploy the valve.

6. If the valve must be re-positioned, proceed to instructions for re-sheathing the valve.

7. If proper placement is confirmed, complete valve deployment by pressing the deployment lock button, then turn the deployment/re-sheath wheel in the direction of the arrow on the handle until the valve capsule is fully retracted.
   NOTE: The deployment/re-sheath wheel will make a clicking sound when the valve capsule is fully retracted.

8. Once the valve is fully deployed, confirm (under fluoroscopy, using orthogonal views) that the retainer tabs have detached from the delivery system retainer receptacle.

Re-Sheathing the Valve (Optional)

If repositioning is required, fully re-sheath the valve by turning the deployment/re-sheath wheel opposite the direction of the arrow on the handle. Return to step 3 of  “Deploying the Valve.”
CAUTION: To prevent potential tissue trauma, close any gap between the valve capsule and the radiopaque tip. If necessary, turn the micro adjustment wheel in the direction of the arrow to close gaps between the valve capsule and the radiopaque tip.
Once the gap is closed, turn the micro adjustment wheel opposite the direction of the arrow until the wheel stops.
CAUTION: Do not re-sheathe the valve more than two times. If additional positioning attempts are needed, completely re-sheath the valve and remove the valve from the patient. Use a new valve and delivery system to complete the procedure.

Post-Deployment
While maintaining the guidewire position, close the delivery system following the instructions below.
CAUTION: Use care to minimize contact between the valve and the radiopaque tip of the delivery system.
a. For transfemoral procedures, withdraw the radiopaque tip of the open delivery system through the valve, into the descending aorta. Depress the macro slide buttons and pull back on the proximal end of the handle to close the system.
Withdraw the delivery system until the valve capsule reaches the integrated sheath.
b. For subclavian/axillary procedures with a separate introducer sheath, begin to withdraw the open delivery system into the introducer. Stop when the radiopaque valve capsule marker band is aligned with the radiopaque band on the introducer.
Maintaining the alignment of the introducer and the valve capsule, depress the macro slide buttons and pull back on the proximal end of the handle to close the system.
c. For subclavian/axillary procedures using the integrated sheath, withdraw the radiopaque tip of the open delivery system through the valve until the valve capsule reaches the integrated sheath. Depress the macro slide buttons and pull back on the proximal end of the handle to close the system.
NOTE: Confirm that the proximal end of the handle is fully retracted before withdrawing the delivery system.
Remove the delivery system and leave the guidewire in the vasculature.
NOTE: Keep the integrated sheath and valve capsule together when withdrawing the delivery system.
Use fluoroscopy to ensure full expansion of the nitinol valve stent. Perform an aortogram to assess the degree of PVL, coronary patency, and valve position. Assess  Hemodynamic function by echo and/or pressure recordings. Greater than MILD PVL should be addressed, during the index procedure, if present.
Close the access site according to standard practice.
NOTE: Patient monitoring for conduction disturbances is recommended.

Patient Registration

A medical device registration form and return envelope are included with each device. Complete the identification card attached to the medical device registration form and provide it to the patient. After implantation, please complete all requested information and return the original form to Abbott.
Tracking by manufacturers is mandatory in some countries. Please disregard any request for patient information if this contradicts your local legal or regulatory requirements regarding patient privacy.
Patient Counseling Information
The risks and benefits of long-term antiplatelet therapy or anticoagulant therapy should be considered. Long-term anticoagulation therapy, unless contraindicated, is recommended for all patients with bioprosthetic heart valves who have risk factors for thromboembolism.
Prophylaxis against infective endocarditis is recommended for patients with prosthetic heart valves and patients with a history of infective endocarditis. Patients with bioprostheses who undergo dental procedures that involve manipulation of gingival tissue or the periapical region of the teeth, or perforation of the oral mucosa should receive endocarditis prophylactic antibiotic therapy.
St. Jude Medical publishes a patient brochure. Copies of this booklet are available through your St. Jude Medical sales representative.
Disposal
These instructions for use is recyclable. Dispose of all packaging materials as appropriate. Dispose of valves, delivery systems and loading systems per standard solid biohazard waste procedures.

Limited Warranty

This limited warranty is available during the warranty period stated below if the implantation system fails to perform consistently with its labeling due to a material defect at the time of manufacturing. This warranty shall continue for a period of one year from delivery of the system to you and is in lieu of, AND ABBOTT MEDICAL HEREBY DISCLAIMS AND EXCLUDES, ALL OTHER WARRANTIES, REPRESENTATIONS, OR CONDITIONS, WHETHER EXPRESS OR IMPLIED BY OPERATION   OF LAW OR OTHERWISE, INCLUDING, BUT NOT LIMITED TO, ANY IMPLIED WARRANTIES OF MERCHANTABILITY, NON-INFRINGEMENT,  COURSE  OF DEALING, QUIET ENJOYMENT, OR FITNESS FOR A PARTICULAR PURPOSE. Handing, storage, cleaning, and sterilization of this system as well as factors relating to the patient, diagnosis, treatment, surgical procedures, and other matters beyond Abbott Medical’s control directly affect this system and the result obtained from its use, and ABBOTT MEDICAL IS NOT RESPONSIBLE FOR THE FOREGOING OR ANY USE OF THE SYSTEM INCONSISTENT WITH OR CONTRARY  TO  THE ABOVE INSTRUCTIONS FOR USE (“IFU”). ABBOTT MEDICAL SHALL NOT BE LIABLE FOR ANY INCIDENTAL, INDIRECT, SPECIAL, COVER, PUNITIVE, OR CONSEQUENTIAL LOSS, DAMAGE, OR EXPENSE DIRECTLY OR INDIRECTLY ARISING FROM THE USE OF OR  RELATED TO THIS SYSTEM. ABBOTT MEDICAL’S SOLE LIABILITY AND YOUR SOLE REMEDY, RELATED TO THE SYSTEM IS THE REPAIR OR  REPLACEMENT OF ALL OR PART OF IT, OR REFUND OF THE SYSTEM PURCHASE PRICE IF REPAIR OR REPLACEMENT IS NOT FEASIBLE AS  DETERMINED BY ABBOTT MEDICAL. IN NO EVENT SHALL ABBOTT MEDICAL BE LIABLE TO YOU OR ANY THIRD PARTY FOR ANY CLAIM OR  DAMAGES, HOWEVER ARISING, IN AN AMOUNT THAT EXCEEDS THE SYSTEM PURCHASE PRICE. ABBOTT MEDICAL neither assumes nor authorizes any other person to assume for it, any other or additional liability or responsibility in connection with this system.
THE ABOVE DISCLAIMERS AND LIMITATIONS SHALL BE CONSTRUED TO COMPLY WITH APPLICABLE LAW, AND THIS LIMITED WARRANTY SHALL  BE REFORMED ACCORDINGLY.
Descriptions of specifications, appearing in Abbott Medical literature, are meant solely to generally describe the system at the time of manufacture and do not constitute any express warranties.

Symbols
The following symbols may be used in this document and on some of the products and packaging:

| Description
---|---
| Catalog Number
| Sterilized using ethylene oxide
| Sterilized by liquid chemical sterilant
| Sterilized using aseptic processing techniques
| Transcatheter heart valve
| Follow instructions for use on this website
| MR Conditional
| Date of Manufacture
| Lot Number
| Temperature limitations
| Do not reuse
| Serial number
| Use by
| Length
| Rinse – 2 x 500 mL x 10 seconds
| Loading System
| Delivery System
| Peel off labels on bottom of tray
| Manufacturer
| Quantity, package contents
| Do not use if package is damaged
| Do not resterilize
| Temperature Indicator: If red, no not use
| Aortic
| Country of manufacture
| Unique device identification number
| Authorized EC Representative in the European Community

2021-08
ARTEN600158216 A

References

• Patents | Abbott Products | Abbott U.S.

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