Continued Access Clinical Trial of the SonRtip Lead and Automatic AV-VV Optimization Algorithm in the PARADYM RF SonR CRT-D

Since the introduction of cardiac resynchronization therapy (CRT) on a large scale, it has
been observed that approximately 30% of recipient patients are non-responsive to therapy.
This non-responsiveness can be decreased by optimizing the device programming, particularly
the stimulation rate, paced and sensed atrioventricular (AV) delay, and the interventricular
(VV) delay.

All CRT patients need a 100% rate of ventricular capture, but beyond this the achievement of
therapy effectiveness requires the identification of the optimal pacing configuration, which
varies among patients. The optimization of CRT systems, usually based on ultrasound imaging
is time-consuming and the number of patients in need of multiple optimization procedures due
to ventricular remodeling is growing rapidly.

The mechanical effects of a more coordinated contraction result in a shortening of the
isovolumetric contraction phase and the pre-ejection time, and an increase in LV dP/dt
(change in left ventricular pressure over time. The concept of measuring contractility with
an implantable accelerometer was first clinically validated through a multicenter study on a
rate responsive pacing system (BEST - Living from SORIN Biomedica) in 1996. This study
positively demonstrates that measurement of Peak Endocardial Acceleration signal (called PEA
or SonR) is feasible and reliable in the long-term, both for the purpose of rate response and
as a hemodynamic monitor of cardiac function.

More recent clinical studies have demonstrated that optimal VV and AV Delays determined using
algorithms based on SonR signal analysis (SonR method) are correlated with the highest
hemodynamic improvement and lead to significant clinical benefit for the patients, thus
reducing the rate of non-responsiveness to CRT therapy.

Therefore, frequent and automatic AV and VV delay optimization in patients with CRT-D devices
could benefit both patients, through increasing the percent of CRT responders, and
clinicians, through simplifying CRT optimization.

The inclusion phase of the "Clinical Trial of the SonRtip Lead and Automatic AV-VV
Optimization Algorithm in the PARADYM RF SonR CRT-D" (RESPOND CRT Study, code ITSY06) has
been completed. A total of 1039 patients have been enrolled in 125 centers in Europe,
Australia and USA, from 13 January 2012 to 14 October 2014.

Safety has been monitored continuously throughout the RESPOND-CRT trial by the Data Safety
Monitoring Board (DSMB). The DSMB charter is to provide recommendations to the Sponsor to
suspend or stop the study if there is clear evidence of harm or harmful side-effects related
to the use of the device or study procedures. To date, there have been no safety concerns
raised by the RESPOND-CRT study data and the DSMB has recommended continuation of the
clinical study.

Additionally, safety is supported by the European marketing history. As the SonR System is CE
marked, RESPONDCRT is being conducted as a post-market study in Europe. Therefore in addition
to the 1000+ patients enrolled in the RESPOND-CRT IDE, an additional 3000+ patients have
received the SonR system outside the study.

As a supplement to the RESPOND CRT IDE Study a Continued Access Study (CAS) is being
conducted according to the potential public health need and preliminary evidence that the
device is likely to be effective with no significant safety concerns for the proposed
indication.

Inclusion Criteria:

- Patients who meet all the following criteria at the time of enrollment may be
included:

1. Patient with a class I and IIa indication for implantation of a CRT-D device
according to current available guidelines

2. Moderate/Severe HF (NYHA Class III or ambulatory IV)

3. LVEF ≤ 35 %

4. LBBB: QRS ≥ 120 ms ; non-LBBB : QRS ≥ 150 ms

5. On a stable optimal drug regimen

6. Patient is in sinus rhythm at the time of signing the informed consent

7. Signed and dated informed consent

Exclusion Criteria:

- Patients who meet any one of these criteria will be excluded from the investigation:

1. Ventricular tachyarrhythmia of transient or reversible causes such as acute
myocardial infarction, digitalis intoxication, drowning, electrocution,
electrolyte imbalance, hypoxia or sepsis, uncorrected at the time of the
enrollment

2. Incessant ventricular tachyarrhythmia

3. Unstable angina, or MI, CABG, or PTCA within the past 4 weeks

4. Correctable valvular disease that is the primary cause of heart failure

5. Recent CVA or TIA (within the previous 3 months)

6. Persistent or permanent atrial arrhythmias (or cardioversion for atrial
fibrillation) within the past month**

7. Post heart transplant (patients who are waiting for a heart transplant are
allowed in the study)

8. Renal failure (GFR<15 ml/min/1.73m2) or on dialysis

9. Previous implant with a CRT- P or CRT-D device

10. Concurrent implant with another pacemaker or ICD system in which all or some of
the components will not be extracted and/or utilized in the new system.
Previously implanted RA leads must be removed prior to implant of the SonRtip
lead.

11. Already included in another clinical study that could confound the results of
this study

12. Life expectancy less than 1 year

13. Inability to understand the purpose of the study or to understand and complete
the QOL questionnaire

14. Unavailability for scheduled follow-up or refusal to cooperate

15. Sensitivity to 1 mg Dexamethasone sodium phosphate (DSP)

16. Age of less than 18 years

17. Pregnancy

18. Substance addiction or abuse

19. Under guardianship