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The Diagnostic Ultrasound System Aplio i900 Model TUS-AI900, Aplio i800 Model TUS-AI800, and Aplio i700 Model TUS-AI700 are indicated for the visualization of structures, and dynamic processes with the human body using ultrasound and to provide image information for diagnosis in the following clinical applications: fetal, abdominal, intra-operative (abdominal), pediatric, small organs (thyroid, breast and testicle), trans-vaginal, trans-rectal, neonatal cephalic, adult cephalic, cardiac (both adult and pediatric), peripheral vascular, transesophageal, musculo-skeletal (both conventional and superficial), laparoscopic and thoracic/pleural. This system provides high-quality ultrasound images in the following modes: B mode, M mode, Continuous Wave, Color Doppler, Pulsed Wave Doppler, Power Doppler and Combination Doppler, as well as Speckle-tracking, Tissue Harmonic Imaging, Combined Modes, Shear wave, Elastography, and Acoustic attenuation mapping. This system is suitable for use in hospital and clinical settings by physicians or appropriately trained healthcare professionals.

In addition to the aforementioned indications for use, when EUS transducer GF-UCT180 and BF-UC190F are connected, Aplio i800 Model TUS-AI800/E3 provides image information for diagnosis of the upper gastrointestinal tract and surrounding organs, airways, tracheobronchial tree and esophagus.

The Aplio i900 Model TUS-AI900, Aplio i800 Model TUS-AI800 and Aplio i700 Model TUS-AI700, V9.0 are mobile diagnostic ultrasound systems. These systems are Track 3 devices that employ a wide array of probes including flat linear array, convex, and sector array with frequency ranges between approximately 2MHz to 33MHz.

This FDA 510(k) clearance letter details the substantial equivalence of the Aplio i900, Aplio i800, and Aplio i700 Software V9.0 Diagnostic Ultrasound System to its predicate device. The information provided specifically focuses on the validation of new and improved features, with particular attention to the 3rd Harmonic Imaging (3-HI), a new deep learning (DL) enabled filtering process.

Acceptance Criteria and Device Performance for 3rd Harmonic Imaging (3-HI)

Detailed Study Information

1. Acceptance Criteria and Reported Device Performance

(See table above)

2. Sample Size Used for the Test Set and Data Provenance

• 3rd Harmonic Imaging (3-HI) Clinical Evaluation:
  • Sample Size: 30 patients.
  • Data Provenance: Previously acquired data from a U.S. clinical site (retrospective). Patients were selected to ensure diverse demographic characteristics representative of the intended U.S. patient population, including a wide range of body mass indices (18.5-36.3 kg/m²), roughly equivalent numbers of males and females, and ages ranging from 23-89 years old.
• 3rd Harmonic Imaging (3-HI) Phantom Study:
  • Sample Size: Five abdominal phantoms.
  • Data Provenance: Phantom data.

3. Number of Experts Used to Establish the Ground Truth for the Test Set and Qualifications

• 3rd Harmonic Imaging (3-HI) Clinical Evaluation:
  • Number of Experts: Three (3).
  • Qualifications: U.S. board-certified radiologists.

4. Adjudication Method for the Test Set

• 3rd Harmonic Imaging (3-HI) Clinical Evaluation:
  • Adjudication Method: Blinded observer study. The three radiologists compared images with 3-HI to images without 3-HI (predicate functionality) using a 5-point ordinal scale. The median score was then compared with the middle score of 3.

5. Multi-Reader Multi-Case (MRMC) Comparative Effectiveness Study

• Yes, a MRMC-like comparative effectiveness study was done for 3-HI's clinical evaluation.
• Effect Size: The statistical analysis demonstrated that scores for 3-HI were higher than the middle score of 3 for spatial resolution, contrast resolution, and artifact suppression. This indicates that human readers (radiologists) rated images with 3-HI as improved compared to those without.

6. Standalone (Algorithm Only Without Human-in-the-Loop Performance)

• Yes, a standalone study was performed for 3-HI in the phantom study. The phantom studies objectively examined lateral and axial resolution, slice resolution, contrast-to-noise ratio (CNR), reverberation artifact suppression, and frequency spectra without human interpretation.

7. The Type of Ground Truth Used

• 3rd Harmonic Imaging (3-HI) Clinical Evaluation:
  • Type of Ground Truth: Expert consensus (from the three board-certified radiologists) on image quality metrics (spatial resolution, contrast resolution, artifact suppression) through a blinded comparison against predicate functionality. The initial selection of patient images included "representative focal pathologies" suggesting clinical relevance in the images themselves.
• 3rd Harmonic Imaging (3-HI) Phantom Study:
  • Type of Ground Truth: Objective measurements against known physical properties and targets within the phantoms.

8. The Sample Size for the Training Set (for 3-HI)

• The document explicitly states that the "The validation data set [30 patients] was entirely independent of the data set used to train the algorithm during its development." However, the actual sample size for the training set is not provided in the given text.

9. How the Ground Truth for the Training Set Was Established (for 3-HI)

• This information is not provided in the given text, beyond the statement that the algorithm was "locked upon completion of development" and had "no post-market, continuous learning capability."

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The AllTest Urinary Tract Infection Test is for the qualitative detection of Leukocytes (white blood cells) and nitrite in urine as an aid in the screening of a Urinary Tract infection (UTI). It is intended for over-the-counter home use only.

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The AiORTA - Plan tool is an image analysis software tool for volumetric assessment. It provides volumetric visualization and measurements based on 3D reconstruction computed from cardiovascular CTA scans. The software device is intended to provide adjunct information to a licensed healthcare practitioner (HCP) in addition to clinical data and other inputs, as a measurement tool used in assessment of aortic aneurysm, pre-operative evaluation, planning and sizing for cardiovascular intervention and surgery, and for post-operative evaluation in patients 22 years old and older.

The device is not intended to provide stand-alone diagnosis or suggest an immediate course of action in treatment or patient management.

AiORTA - Plan is a cloud-based software tool used to make and review geometric measurements of cardiovascular structures, specifically abdominal aortic aneurysms. The software uses CT scan data as input to make measurements from 2D and 3D mesh based images. Software outputs are intended to be used as a measurement tool used in assessment of aortic aneurysm, pre-operative evaluation, planning and sizing for cardiovascular intervention and surgery, and for post-operative evaluation.

The AiORTA - Plan software consists of two components, the Analysis Pipeline and Web Application.

The Analysis Pipeline is the data processing engine that produces measurements of the abdominal aorta based on the input DICOM images. It consists of multiple modules that are operated by a trained Analyst to preprocess the DICOM images, compute geometric parameters (e.g., centerlines, diameters, lengths, volumes), and upload the results to the Web App for clinician review. The Analyst plays a role in ensuring the quality of the outputs. However, the end user (licensed healthcare practitioner) is ultimately responsible for the accuracy of the segmentations, the resulting measurements, and any clinical decisions based on these outputs.

The workflow of the Analysis Pipeline can be described in the following steps:

• Input: the Analysis Pipeline receives a CTA scan as input.
• Segmentation: an AI-powered auto-masking algorithm performs segmentation of the aortic lumen, wall, and key anatomical landmarks, including the superior mesenteric, celiac, and renal arteries. A trained Analyst performs quality control of the segmentations, making any necessary revisions to ensure accurate outputs.
• 3D conversion: the segmentations are converted into 3D mesh representations.
• Measurement computation: from the 3D representations, the aortic centerline and geometric measurements, such as diameters, lengths, and volumes, are computed.
• Follow-up study analysis: for patients with multiple studies, the system can detect and display changes in aortic geometry between studies.
• Report generation: a report is generated containing key measurements and a 3D Anatomy Map providing multiple views of the abdominal aorta and its landmarks.
• Web application integration: the outputs, including the segmented CT masks, 3D visualizations, and reports, are uploaded to the Web App for interactive review and analysis.

The Web Application (Web App) is the front end and user facing component of the system. It is a cloud-based user interface offered to the qualified clinician to first upload de-identified cardiovascular CTA scans in DICOM format, along with relevant demographic and medical information about the patient and current study. The uploaded data is processed asynchronously by the Analysis Pipeline. Once processing is complete, the Web App then enables clinicians to interactively review and analyze the resulting outputs.

Main features of the Web App include:

• Segmentation review and correction: Clinicians can review the resulting segmentations from the Analysis Pipeline segmentations by viewing the CT slices alongside the segmentation masks. Segmentations can be revised using tools such as a brush or pixel eraser, with adjustable brush size, to select or remove pixels as needed. When clinicians revise segmentations, they can request asynchronous re-analysis by the Analysis Pipeline, which generates updated measurements and a 3D Anatomy Map of the aorta based on the revised segmentations.
• 3D visualization: The aorta and key anatomical landmarks can be examined in full rotational views using the 3D Anatomy Map.
• Measurement tools: Clinicians can perform measurements directly on the 3D Anatomy Map of the abdominal aorta and have access to a variety of measurement tools, including:
  • Centerline distance, which measures the distance (in mm) between two user-selected planes along the aortic centerline.
  • Diameter range, which measures the minimum and maximum diameters (in mm) within the region of interest between two user-selected planes along the aortic centerline.
  • Local diameter, which measures the diameter (in mm) at the user-selected plane along the aortic centerline.
  • Volume, which measures the volume (in mL) between two user-selected planes along the aortic centerline.
  • Calipers, which allow additional linear measurements (in mm) at user-selected points.
• Screenshots: Clinicians can capture images of the 3D visualizations of the aorta or the segmentations displayed on the CT slices.
• Longitudinal analysis: For patients with multiple studies, the Web App allows side-by-side review of studies. Clinicians have access to the same measurement and visualization tools available in single-study review, enabling comparison between studies.
• Reporting: Clinicians can generate and download reports containing either the default key measurements computed by the Analysis Pipeline or custom measurements and screenshots captured during review.

Here's a breakdown of the acceptance criteria and the study details for the AiORTA - Plan device, based on the provided FDA 510(k) clearance letter:

Acceptance Criteria and Reported Device Performance

Explanation for Lengths and Diameters that did not meet initial criteria:
For the following measurements which did not meet the initial acceptance criteria:

• Length: renal to left iliac bifurcation (7.0mm vs ≤ 6.0mm)
• Length: renal to right iliac bifurcation (6.6mm vs ≤ 6.0mm)
• Diameter: wall right iliac (2.5mm vs ≤ 2.3mm)

A Mean Pairwise Absolute Difference (MPAD) comparison was performed. The device-expert MPAD was smaller than the expert-expert MPAD in all three cases, indicating that the device's measurements were more consistent with experts than the experts were with each other.

Study Details for Device Performance Evaluation:

1. Sample size used for the test set and the data provenance:

   • Auto-segmentation masks and Landmark Identification: The document does not explicitly state the sample size for this specific test, but it mentions using "clinical data, including aortic aneurysm cases from both US and Canadian clinical centers."
   • Diameters and Lengths: The document does not explicitly state the sample size for this specific test, but it mentions using "clinical data, including aortic aneurysm cases from both US and Canadian clinical centers."
   • Volumes: 40 CT scans. The data provenance is "clinical data, including aortic aneurysm cases from both US and Canadian clinical centers." The studies were retrospective, as they involved existing clinical data.

2. Number of experts used to establish the ground truth for the test set and the qualifications of those experts:

   • Auto-segmentation masks and Landmark Identification: 3 US-based board-certified Radiologists.
   • Diameters and Lengths: 3 US-based board-certified Radiologists.
   • Volumes: The ground truth for volumes was established using a reference device (Simpleware ScanIP Medical), not directly by human experts, although the input segmentations for both the device and the reference device were analyst-revised.

3. Adjudication method for the test set:

   • Auto-segmentation masks and Landmark Identification: Ground truth was "annotations approved by 3 US-based board-certified Radiologists." This implies consensus or a primary reader with adjudication, but the exact method (e.g., 2+1, 3+1) is not specified.
   • Diameters and Lengths: Ground truth was "annotations from 3 US-based board-certified Radiologists." Similar to above, the specific consensus method is not detailed.
   • Volumes: Ground truth was established by a reference device, Simpleware ScanIP Medical.

4. If a multi reader multi case (MRMC) comparative effectiveness study was done, If so, what was the effect size of how much human readers improve with AI vs without AI assistance:

   • No MRMC comparative effectiveness study was explicitly mentioned in the provided text. The testing focused on the standalone performance of the AI-powered components and the consistency of the device's measurements with expert annotations, not on human reader improvement with AI assistance.

5. If a standalone (i.e., algorithm only without human-in-the loop performance) was done:

   • Yes, a standalone performance evaluation of the auto-masking algorithm (prior to analyst correction) was performed for auto-segmentation masks and landmark identification. The results demonstrated the performance of the auto-masking algorithm "independently of human intervention."
   • However, for diameters and lengths, the measurements were "based on segmentations that underwent Analyst review and correction, ensuring that the verification reflects real-world use conditions." This suggests a semi-automatic, human-in-the-loop performance evaluation for these specific metrics.

6. The type of ground truth used (expert concensus, pathology, outcomes data, etc):

   • Expert Consensus: Used for auto-segmentation masks, landmark identification, diameters, and lengths. The consensus involved 3 US-based board-certified Radiologists.
   • Reference Device: Used for volumes, comparing against results from Simpleware ScanIP Medical.

7. The sample size for the training set:

   • The document does not explicitly state the sample size for the training set. It mentions "critical algorithms were verified by comparing their outputs to ground truth data to ensure accuracy and reliability. Algorithms were first verified using synthetic data...Subsequent verification was performed using clinical data, including aortic aneurysm cases from both US and Canadian clinical centers." This refers to verification data, not necessarily the training data size.

8. How the ground truth for the training set was established:

   • The document does not provide details on how the ground truth for the training set was established. It only describes the ground truth for the verification/test sets. It can be inferred that similar expert review or other validated methods would have been used for training data, but this is not explicitly stated.

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The Arctx Cool Catheter Set is a thermal regulating device, intended to: connect to a Blanketrol III Hyper-Hypothermia System to control patient temperature, allow enteral administration of fluids, and provide gastric decompression and suctioning.

The ACC Set is comprised of the Arctx Catheter and the Arctx Extension Line.

The ACC Set is intended to cool or warm a patient's temperature for up to 72 hours when connected to a commercial external thermal regulating system, provide gastric decompression and suctioning, and allow enteral administration of fluids. The Arctx Catheter is inserted through the nasopharynx, past the oropharynx and into the esophagus and stomach/duodenum where two lumens deliver cooled or heated water in a closed circuit, from a commercial thermal regulating system to control patient temperature. The circulating water does not contact the patient.

A third catheter lumen enables gastric suction and decompression as well as enteral administration of fluids.

The Arctx Catheter is made of standard medical-grade thermoplastic elastomers. It is a single-use, disposable, non-implantable device. The ACC Set has a quick-connect system that allows the Arctx Catheter to be easily disconnected from the Arctx Extension Line while the catheter remains in place. The quick-connect system allows the patient to move around freely for bathroom breaks, and other medical procedures outside the hospital room. The Arctx Catheter connects to the external thermal regulating system via the Arctx Extension Line.

The ACC Set is intended to be used with the Gentherm Medical Blanketrol III System, model #233. The Blanketrol III System supplies temperature-controlled water through a connector conduit to the ACC Set. An accessory temperature probe interfaces with the Blanketrol and the patient to measure patient temperature, which is displayed on the Blanketrol III System control panel. The Blanketrol III System controls water temperature by mixing hot and cold water using hot and cold solenoid valves under microprocessor control, and includes a circulating pump, heater, and refrigeration system.

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The AIR COMPRESSION BOOTS is intended for the temporary relief of minor muscle aches and pains and for temporary increase in blood circulation to the treated areas in people who are in good health. The AIR COMPRESSION BOOTS simulates kneading and stroking of tissues by using an inflatable garment.

This product operates through an air pump stored internally, sending air into the air bag, inflating and deflating through the alternate work of the solenoid valve, and squeezing the leg to achieve a massage effect. This product consists of hand controller, air pump, air valve and leg bag. The following model numbers are identical in circuitry and electrical, mechanical and physical construction; the only differences are the size and model number for trading purpose. The model 1018196 is for the 26-inch size and model 1018195 is for the 32-inch size.

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The Arthrex BioComposite 2.0 mm SutureTak Suture Anchor is intended for suture (soft tissue) fixation to bone in the elbow, shoulder, hand/wrist, foot/ankle, knee, and hip in the following procedures:

• Elbow: Biceps Tendon Reattachment, Ulnar or Radial Collateral Ligament Reconstruction
• Shoulder: Rotator Cuff Repair, Bankart Repair, SLAP Lesion Repair, Biceps Tenodesis, Acromio-Clavicular Separation Repair, Deltoid Repair, Capsular Shift or Capsulolabral Reconstruction
• Hand/Wrist: Scapholunate Ligament Reconstruction, Carpal Ligament Reconstruction, Repair/Reconstruction of collateral ligaments, Repair of Flexor and Extensor Tendons at the PIP, DIP, and MCP joints for all digits, digital tendon transfers
• Foot/Ankle: Lateral Stabilization, Medial Stabilization, Achilles Tendon Repair, Metatarsal Ligament Repair, Hallux Valgus Reconstruction, Digital Tendon Transfers, Mid-Foot Reconstruction
• Knee: Medial Collateral Ligament Repair, Lateral Collateral Ligament Repair, Patellar Tendon Repair, Posterior Oblique Ligament Repair, Iliotibial Band Tenodesis
• Hip: Acetabular Labral Repair and Reconstruction

The Arthrex PEEK Mini Hip SutureTak is intended to be used for suture (soft tissue) fixation to bone in the hip. Specifically, Acetabular Labral Repair and Reconstruction.

The fundamental technology of the Arthrex SutureTak Suture Anchor is that the Arthrex SutureTak Suture Anchors are "hard-bodied" fixation devices with anchors manufactured from either BioComposite or PEEK material. The subject anchors are preassembled to suture manufactured from UHMWPE and Polyester. The anchor is first impacted into a pilot hole. Once the anchor is set, the suture is passed around the soft tissue and is fixated via its surgical technique. The devices are provided sterile, are single-use, and are packaged in a dual barrier packaging configuration.

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The AETOS Shoulder System (when used with the AETOS Humeral Meta Stems) is to be used only in patients with an intact or reconstructable rotator cuff, where it is intended to provide increased mobility and stability and to relieve pain.

The AETOS humeral stems (AETOS Humeral Meta Stems) and head may be used by themselves, as a hemiarthroplasty, if the natural glenoid provides a sufficient bearing surface, or in conjunction with the glenoid, as a total replacement.

When used with the AETOS Humeral Meta Stems, The AETOS Shoulder System is indicated for use as a replacement of shoulder joints disabled by:

• Rheumatoid arthritis
• Non-inflammatory degenerative joint disease
• Correction of functional deformity
• Fractures of the humeral head
• Traumatic arthritis
• Revision of other devices if sufficient bone stock remains

The AETOS Shoulder System (when used with AETOS Stemless Humeral Prosthesis) is to be used only in patients with an intact or reconstructable rotator cuff.

When used with AETOS Stemless Humeral Prosthesis, the AETOS Shoulder System is indicated for anatomic total shoulder replacement of shoulder joints disabled by:

• Non-inflammatory degenerative joint disease
• Traumatic arthritis
• Revision of other devices if sufficient bone stock remains

The coated humeral components are intended for uncemented use. The glenoid component is intended for cemented use only.

In Reverse:

The AETOS Shoulder System, when used with AETOS Humeral Meta Stems, is indicated for use as a replacement of shoulder joints for patients with a functional deltoid muscle and with massive and non-repairable rotator cuff-tear with pain disabled by:

• Rheumatoid arthritis
• Non-inflammatory degenerative joint disease
• Correction of functional deformity
• Fractures of the humeral head
• Traumatic arthritis
• Revision of devices if sufficient bone stock remains

The humeral liner component is indicated for use in the AETOS Shoulder System as a primary reverse total shoulder replacement and for use when converting an anatomic AETOS Shoulder System into a reverse shoulder construct. This facilitates the conversion without the removal of the humeral stem during revision surgery for patients with a functional deltoid muscle. The component is permitted to be used in the conversion from anatomic to reverse if the humeral stem is well fixed, the patient has a functional deltoid muscle; the arthroplasty is associated with a massive and non-repairable rotator cuff tear.

The coated humeral stems are indicated for uncemented use. The coated glenoid base plate is intended for cementless application with the addition of screws for fixation.

Note: All implant components are single use.

The AETOS Shoulder System Meta Humeral Prosthesis Size 0 subject to this submission is intended for press-fit fixation as of an implant construct in anatomic and/or reverse total shoulder arthroplasty for the treatment of skeletally mature individuals with degenerative diseases of the glenohumeral joint.

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The AngioVac Cannula is indicated for use as a venous drainage cannula and for removal of fresh, soft thrombi or emboli during extracorporeal bypass for up to 6 hours.

The AngioVac Cannula is a venovenous cannula with a nitinol basket reinforced, self-expandable funnel shaped distal tip collapsed using an over-sheath that can be advanced through a 26 Fr sheath and over a guidewire into the venous system percutaneously or via a surgical cut-down. During use, the cannula is connected to an extracorporeal circuit, an AngioVac Circuit, a commercially available centrifugal pump and bubble trap. A commercially available reinfusion cannula is placed for venous return (typically within internal jugular or one of the common femoral veins) and connected to the extracorporeal circuit. The funnel tip is actuated by advancing the AngioVac Cannula out of the sheath deploying the self-expanding nitinol reinforced funnel shaped tip at the desired tip angle. Once optimal flow rate is achieved, the AngioVac Cannula is advanced under image guidance towards the undesirable intravascular (i.e. thrombus or emboli) until it is engaged, suctioned into the cannula and removed from the vasculature. The blood is then circulated though the filter and returned to the patient via the venous return cannula. A benefit of the AngioVac Cannula is that it allows for removal of thrombus and embolic material, while minimizing blood loss via recirculation of blood through a standard extracorporeal (venovenous) bypass circuit. Target vessels for the thrombus/embolus extraction include but are not limited to, the iliofemoral vein, Inferior Vena Cava (IVC), Superior Vena Cava (SVC) and Right Atrium (RA). The device is provided in ~20° (AngioVac C20) and ~180° (AngioVac C180) angled configurations.

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The Azurion series (within the limits of the used Operating Room table) are intended for use to perform:

• Image guidance in diagnostic, interventional and minimally invasive surgery procedures for the following clinical application areas: vascular, non-vascular, cardiovascular and neuro procedures.
• Cardiac imaging applications including diagnostics, interventional and minimally invasive surgery procedures.

Additionally:

• The Azurion series can be used in a hybrid Operating Room.
• The Azurion series contain a number of features to support a flexible and patient centric procedural workflow.

Patient Population:
All human patients of all ages. Patient weight is limited to the specification of the patient table.

The Azurion R3.1 is classified as an interventional fluoroscopic X-Ray system. The primary performance characteristics of the Azurion R3.1 include:

• Real-time image visualization of patient anatomy during procedures
• Imaging techniques and tools to assist interventional procedures
• Post processing functions after interventional procedures
• Storage of reference/control images for patient records
• Compatibility with hospital information systems (HIS) and image archiving systems via DICOM
• Built in radiation safety controls

This array of functions offers the physician the imaging information and tools needed to perform and document minimally invasive interventional procedures.

The Azurion R3.1 is available in identical models and configurations as the predicate device Azurion R2.1. Configurations are composed of detector type, monoplane (single C-arm) or biplane (dual arm), floor or ceiling mounted geometry, standard or OR table type and available image processing.

Identical to the predicate device, the FlexArm option is available for the 7M20 configuration in Azurion R3.1 to increase flexibility in stand movement.

Additionally, identical to the predicate device, Azurion R3.1 can be used in a hybrid operating room when supplied with a compatible operating room table.

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Atalante X is intended to perform ambulatory functions and mobility exercises, hands‐free, in rehabilitation institutions under the supervision of a trained operator for the following populations:

• Individuals with hemiplegia due to cerebrovascular accident (CVA)
• Individuals with spinal cord injuries at levels C4 to L5 (SCI)
• Individuals with multiple sclerosis (MS)

The operator must complete a training program prior to use of the device.

Atalante X is intended to be used on adolescents of 18 years and older and adults, able to tolerate a stand‐up position.

The device is not intended for sports or stair climbing.

Atalante X is a completely self‐balancing walking system for people with mobility disabilities. It is a fully powered hip‐knee‐ankle lower body exoskeleton with 12 actuated degrees of freedom. Atalante X is self‐balancing and includes dynamic‐walking control. Dynamic‐walking allows the Atalante X to consume significantly less power and have a more natural gait.

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