REFLECT II clinical trial evaluates safety and efficacy of cerebral embolic deflection filter

The REFLECT II randomized clinical trial evaluating the safety and efficacy of a device designed to reduce cerebral embolization and ischemic stroke, complications of transcatheter aortic valve replacement (TAVR), found that the device met the primary safety endpoint compared to historical controls but did not demonstrate superiority of the device for the primary hierarchical efficacy endpoint.

Findings were reported today at TCT Connect, the 32nd annual scientific symposium of the Cardiovascular Research Foundation (CRF). TCT is the world's premier educational meeting specializing in interventional cardiovascular medicine.

The REFLECT II trial evaluated the safety and effectiveness of the TriGuard 3 (TG3), a self-stabilizing cerebral embolic deflection filter, in patients undergoing TAVR. REFLECT II intended to randomize 295 patients 2:1 to TAVR with TG3 vs. control.

The primary safety endpoint was a composite of all-cause mortality, stroke, life-threatening or disabling bleeding, stage 2/3 acute kidney injury, coronary artery obstruction requiring intervention, major vascular complication, and valve-related dysfunction requiring intervention (VARC 2 defined) at 30 days.

The endpoint was compared with a Performance Goal (PG) of 34.4%. The primary efficacy endpoint was a hierarchical composite of all-cause mortality or stroke at 30 days, NIHSS worsening, absence of diffusion-weighted magnetic resonance imaging (DWI) lesions post-procedure, and total volume of cerebral lesions (TLV) by DWI.

Cumulative scores derived by the Finkelstein-Schoenfeld method were summed for each patient and compared between groups.

The REFLECT II analysis population included 283 patients [41 roll-in, 121 randomized to TG3 and 121 controls (58 randomized in phase II and 63 pooled from REFLECT phase I)].

TG3 was delivered and positioned in the aortic arch prior to TAVR in 100% of cases and retrieved intact in all cases.

After enrollment of 179 of the 225 planned randomized patients, the sponsor suspended trial enrollment with the concurrence of the FDA and DMC. After limited unblinding and review of the data, Keystone Heart decided to formally close the study and proceed with the marketing application (510(k)).

TG3 met the primary safety endpoint (22.5% vs 34.4% PG, pnon-inferiority=0.0001). However, superiority for the primary efficacy endpoint was not met, with similar win-ratios and win% (TG3 0.84 (45.7%) vs 1.19 (54.3%), p=0.857) between groups. Median TLV was not different with TG3 protection (215.39 mm3 vs 188.09 mm3, p=0.405).

Compared to controls, the primary 30-day safety endpoint was higher with TriGuard 3 due primarily to TAVR related vascular and bleeding complications."

Jeffrey W. Moses, MD, Professor of Cardiology, Vagelos College of Physicians and Surgeons, Columbia University

Moses is also a director of Interventional Cardiovascular Therapeutics, NewYork-Presbyterian/Columbia University Irving Medical Center and Director of Advanced Cardiac Interventions, St. Francis Hospital and Heart Center.

"While the study did not demonstrate superiority of TriGUARD 3 compared to pooled controls for the primary hierarchical efficacy endpoint, a post hoc DW-MRI analysis suggests that TG3 may reduce larger ischemic lesions. Improved device stability to achieve reliable, complete cerebral coverage may improve outcomes."