Meital Mazor Ph D Vessix Vascular Boston Scientific

Meital Mazor, Ph. D Vessix Vascular, Boston Scientific PI-136107 -AA Jan 2013 -final 0 of 26 Pre-Clinical Evaluation of Renal Denervation with RF Technologies

Meital Mazor, Ph. D Within the past 12 months, I have had a financial interest/arrangement or affiliation with the organization(s) listed below. Vessix Vascular, Inc. Employee and stockholder Boston Scientific Employee

In human arteries…. PI-136107 -AA Jan 2013 -final 3 of 26 many parameters are involved in the efficacy of renal denervation

Significantly more nerves in hypertensive patient vs. normotensive subjects Normotensive Patient 32 renal human arteries included. The number of nerves per mm 2 within the 0. 5 mm ring area from the adventitia was 2. 5± 1. 8 in N vs. 3. 5± 1. 4 in H (p<0. 04) while no difference was detected above 0. 5 mm (1. 5± 0. 9 in N vs. 1. 2± 0. 7 in H, p=0. 3). Giuseppe Sangiorgi et al. J Am Coll Cardiol. 2012; 60(17_S) PI-136107 -AA Jan 2013 -final 4 of 26 Hypertensive Patient

64% of the arteries included in this analysis are atherosclerotic Histology images and figure were taken from Renu Virmani, LINC 2013 PI-136107 -AA Jan 2013 -final 5 of 26 In renal arteries, atherosclerosis increases the distance between the catheter and the nerves

PI-136107 -AA Jan 2013 -final 6 of 26 In healthy porcine…. .

No hypertension, No hypertensive medications, No atherosclerosis, Thinner arteries (Tunica PI-136107 -AA Jan 2013 -final 7 of 26 media thickness is about half of humans)

Energy Catheter Design Medtronic Symplicity™ St. Jude Enlig. HTN™ Covidien (Maya) One. Shot™ Boston Scientific Vessix™ RF Monopolar RF Bipolar Catheter with single electrode Basket with four electrodes Balloon with helical electrode and irrigation Balloon with four to eight electrode pairs 0. 014” or 0. 018” (0. 36 mm or 0. 46 mm) Guidewire No No 0. 014” (0. 36 mm) Power (watts) 5 -8 6 25 ~1 Generator Control Power Temperature System Single Activation Time 2 minb 6 minc 2 mind 30 sec Total Denervation Time 24 min 2 min a None of these devices are available for sale in the US. Website. c St. Jude Website. d Covidien (Maya) Presentation; Ormiston et al. Euro. Intv. 2013. *The Vessix™ Renal Denervation System is not available for sale in the US. b Medtronic N/A= Not Reported RF=Radiofrequency PI-136107 -AA Jan 2013 -final 8 of 26 RF Renal Denervation Systemsa

Monopolar RF (Single or Multiprobe) Grounding Pad Surrounding Tissue Blood Vessel Wall Dissipated Energy • • RF energy is dispersed through the body and terminates into a grounding pad placed on patient’s thigh. • • Arteries <4. 0 mm cannot be treated, since there is not enough perfusion of blood to cool catheter. Requires perfusion of blood in the artery to cool the catheter. Significant power (6 to 8 watts) is required to reach an effective temperature. Significant heat is lost into the bloodstream requiring long therapy “dwell times” (1. 5 -2. 0 minutes) in order to get depth of penetration into the adventitia. Long treatment times extends possible pain for the patient. PI-136107 -AA Jan 2013 -final 9 of 26 Blood Flow

Symplicity PI-136107 -AA Jan 2013 -final 10 of 26 • Released Energy maximum 8 Watt • Temperature between 40 -75° • The generator automatically switch off if temperature is higher than 75 °

PI-136107 -AA Jan 2013 -final 11 of 26 Sievert H. et al. 2009 ICI

Swine artery at 10 day post MP RDN • Steigerwald K, et al. Morphological assessment of renal arteries after radiofrequency catheter-based sympathetic denervation in a porcine model. J Hypertens. 2012 Nov; 30(11): 2230 -9. PI-136107 -AA Jan 2013 -final 12 of 26 Endothelization almost complete • Full media thickness was constituted with fibrotic tissue • Pronounced adventitial inflammation • Amount of microfilament stained nerves was reduced by 45%.

Mono-polar RDN- 180 days • The RF-induced lesions were well healed and devoid of any significant inflammatory component. • The lesions consisted of fibrosis, and minimal to mild disruption of the external elastic lamina. PI-136107 -AA Jan 2013 -final 13 of 26 • Minimal intimal thickening and minimal disruption of the internal elastic lamina were seen in all treated renal arteries Rippy MK et al. Clin Res Cardiol. 2011 Dec; 100(12): 1095 -101.

The renal nerve injury was characterized primarily as healing fibrosis causing a thickening of the surrounding perineurium in affected nerves. Rippy MK et al. Clin Res Cardiol. 2011 Dec; 100(12): 1095 -101. PI-136107 -AA Jan 2013 -final 14 of 26 Nerve injury at 180 days

PI-136107 -AA Jan 2013 -final 15 of 26 ESC 2008, Henry Krum

Bipolar RF on a Balloon Surrounding Tissue Blood Vessel Wall • Bipolar RF energy travels only from a positive to negative pole located on each electrode thereby localizing the energy and eliminating the necessity of a grounding pad. • Balloon occludes blood flow; no heat is lost to bloodstream, thus creating an efficient environment to deliver energy. • Since perfusion of the blood is not needed to cool catheter, small diameter balloons allow treatment in accessory renal arteries. • • Allows delivery of very low power (0. 5 to 1 watt). • Fast treatment time may mitigate pain for the patient. Allows for simultaneous delivery of energy to multiple electrodes and very fast treatment times (in the case of The Vessix™ Renal Denervation System total of 30 seconds for all 8 electrodes). PI-136107 -AA Jan 2013 -final 16 of 26 No Blood Flow

2 V Vessix System Renal Denervation • Low pressure non-compliant balloon (3 atm) with offset helical pattern of bi-polar electrodes • Very low power (typically <1. 0 Watt/electrode) needed to reach and maintain target temperature • Generator confirms apposition via impedance. Electrodes not properly apposed to tissue are automatically turned off PI-136107 -AA Jan 2013 -final 17 of 26 • Custom RF Generator controls temperature at precisely 68◦C and delivers RF energy to all electrodes simultaneously.

PI-136107 -AA Jan 2013 -final 18 of 26 Porcine artery 7 days post bipolar RF treatment

Treatment zone was evidenced by transmural coagulative necrosis of the arterial wall and extension of the zones of treatment into the adjacent adventitia (within dashed lines). Susceptible nerves are nerves adjacent to or within the zone of treatment (within dashed line), while non-susceptible nerves are nerves outside of zone of treatment. Note: hemorrhage within adventitia is an artifact related to histology processing PI-136107 -AA Jan 2013 -final 19 of 26 Zone of RF Treatment

Degenerate/reactive nerve within zone of treatment Loss of normal fiber morphology characterized by: PI-136107 -AA Jan 2013 -final 20 of 26 • Disorganized hypercellularity • Vacuolization • Perineural fibroplasia/fibrosis

PI-136107 -AA Jan 2013 -final 21 of 26 Single treatment per artery (n=3)

PI-136107 -AA Jan 2013 -final 22 of 26 Treatment of full artery length (n=3)

PI-136107 -AA Jan 2013 -final 23 of 26 Single treatment with horizontally placed electrodes (n=3)

RF treatment throughout the entire artery length affected more nerves within the zone of treatment (p<0. 05), and caused the highest decrease in NEPI levels. -78% NEPI -41% NEPI The group with surgical denervation showed a 75% reduction in NEPI, compared to the endogenous NEPI level of the untreated controls. PI-136107 -AA Jan 2013 -final 24 of 26 -46% NEPI

Affected nerves= susceptible nerves and affected unsusceptible nerves PI-136107 -AA Jan 2013 -final 25 of 26 Full artery length treatment affected significantly higher percentage of overall nerves (in and outside the zone of treatment).

NEPI correlation to percentage of affected nerves Affected nerves (%) PI-136107 -AA Jan 2013 -final 26 of 26 r=0. 6

Vascular Safety in Treated Swine Renal Arteries is Demonstrated through 180 Days Pre Treatment 180 Days Post Treatment • • surrounding tissue All treated arteries were patent No dissections, aneurysms, or changes in blood or urine chemistry Endothelialization by 7 days Significant reduction in norepinephrine through 180 days Vessix™ data on file *The Vessix™ Renal Denervation System is not available for sale in the US. Balloon Location PI-136107 -AA Jan 2013 -final 27 of 26 • Histology confirms no adverse effect on Swine model results not necessarily indicative of clinical performance

PI-136107 -AA Jan 2013 -final 28 of 26 Thank you