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TCTAP 2025

TAVR in Bicuspid Aortic Valve Stenosis : Challenges, Data, and Strategies From Asan Medical Center

In the “TAVR: Current Status and Future Perspective” session at TCTAP 2025, Dr. Jung-Min Ahn (Asan Medical Center, Korea) presented a comprehensive lecture on transcatheter aortic valve replacement (TAVR) in patients with bicuspid aortic valve (BAV), addressing the key anatomical, procedural, and clinical challenges that distinguish BAV from the more commonly studied tricuspid aortic valve. Jung-Min Ahn Asan Medical Center, Korea (Republic of) Although early randomized trials in TAVR excluded BAV patients due to their complex anatomy, recent evidence—including results from PARTNER III and other contemporary registries—has supported TAVR’s effectiveness even in low-risk populations. Notably, the average patient age in current TAVR cohorts has decreased from 82–84 years in early trials to around 74 years today, increasing the prevalence of BAV cases encountered in real-world practice. BAV patients are typically younger, more often male, and have fewer comorbidities. However, their anatomical profile is more challenging: severe aortic stenosis with higher transvalvular gradients, larger and more asymmetric valve complexes, and substantially greater calcification volume compared with tricuspid aortic stenosis. These features raise both periprocedural and long-term risks, necessitating a more cautious approach to valve sizing and deployment. Figure 1. Clinical and Anatomical Challenges in Bicuspid Aortic Valve Stenosis The Asan Medical Center data demonstrated that in BAV cases, operators more frequently performed both pre- and post-dilatation and tended to implant larger valves than in tricuspid cases. Despite these differences, echocardiographic outcomes—including effective orifice area and transvalvular gradients—were similar at two-year follow-up. Rates of death and stroke were also comparable. To better understand the safety and efficacy of TAVR in BAV patients, Dr. Ahn presented results from a comprehensive meta-analysis comparing outcomes between BAV and TAV aortic stenosis patients. Among over 13,000 patients from 34 studies, procedural complications were significantly more frequent in BAV TAVR recipients. Notably, the risk of moderate-or-worse paravalvular leakage was increased by 59%, while the rate of permanent pacemaker implantation showed no significant difference. However, aortic root injury occurred 81% more often in BAV cases. Major bleeding rates were comparable between the two groups. Furthermore, the meta-analysis identified a small but statistically significant increase in early adverse events in BAV patients: the 30-day mortality risk was elevated by 34%, and the risk of stroke increased by 27% compared to TAV patients. These findings underscore the importance of anatomical assessment and individualized procedural strategies in BAV TAVR. Figure 2. Comparative Outcomes of TAVR in Bicuspid versus Tricuspid Aortic Valve Stenosis Dr. Ahn concluded, “While BAV remains a complex entity, TAVR has proven to be both feasible and effective, but requires individualized planning with careful attention to anatomy, calcium distribution, and valve sizing.” This session emphasized the critical role of imaging-guided, anatomy-specific strategies in optimizing TAVR outcomes for this unique and increasingly encountered patient population. TAVR: Current Status and Future Perspective Saturday, April 26, 9:50 AM-11:10 AM Coronary Theater, Level 1 Check The Session

May 23, 2025 1205

TCTAP 2025

Transcatheter Mitral Valve Intervention: Exploring the Future of TMVI Therapies

At TCTAP 2025, during the “Mitral and Tricuspid Intervention” session held on April 25, Dr. Juan F. Granada (Cardiovascular Research Foundation, USA) delivered a compelling presentation titled “Transcatheter Mitral Valve Intervention: What Is Next?” His lecture offered a comprehensive review of recent innovations in mitral valve therapies and addressed the clinical limitations of current approaches while presenting an optimistic view of evolving transcatheter solutions. Juan F. Granada Cardiovascular Research Foundation, USA He began by outlining the historical progression from surgical mitral valve repair/replacement (dating back to the 1960s) to current transcatheter mitral edge-to-edge repair (M-TEER). He emphasized how iterative innovations have expanded treatment indications, including valve-in-valve, valve-in-ring, and secondary MR (SMR) in high-risk patients. He highlighted the complexity of MR cases, particularly among patients with severe mitral annular calcification (MAC), multiple cleft leaflets, or bioprosthetic failure. These anatomies often render patients unsuitable for M-TEER, necessitating new TMVI platforms. He pointed out that while TEER remains a safe and effective option, especially in high-volume centers, it has shown reduced efficacy in complex anatomies and higher residual MR rates in low-volume centers. He presented future directions involving augmentation devices and leaflet extensions, along with refined imaging tools and device reversibility mechanisms. A significant portion of the lecture focused on the emerging transcatheter mitral valve replacement (TMVR) systems, such as Cephea, AltaValve, Tioga, and Intrepid. He reviewed early feasibility and pivotal study outcomes, comparing rates of surgical conversion, vascular complications, bleeding, and 1-year mortality across different platforms. Among them, Cephea demonstrated notable procedural success and safety, supporting its role in non-surgical, anatomically challenging patients. He concluded by identifying key hurdles to TMVR adoption—namely, high screen failure rates, anatomical variability, and frailty concerns. However, ongoing advancements in device adaptability, delivery systems, and ancillary procedural tools are steadily addressing these barriers. Dr. Granada’s presentation reinforced the notion that next-generation TMVI technologies must be patient-centric, anatomically versatile, and outcome-driven. His forward-looking perspective underscored the potential of TMVI to reshape the management of mitral regurgitation in the coming decade. Figure 1. Comparative overview of major TMVR platforms in early feasibility studies. Adapted from Granada JF, TCTAP 2025. Mitral and Tricuspid Intervention Friday, April 25, 10:30 AM-12:15 PM Valve & Endovascular Theater, Level 1 Check The Session

May 23, 2025 640

TCTAP 2025

Current Challenges and Future Directions in Valve-in-Valve Procedures

Tullio Palmerini University of Bologna, Italy At TCTAP 2025, during the “TAVR: Current Status and Future Perspective” session held on April 26 in the Coronary Theater, Dr. Tullio Palmerini (University of Bologna, Italy) delivered a comprehensive overview of the current landscape and persistent challenges in valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR). As the use of bioprosthetic surgical valves continues to rise, so does the clinical relevance of ViV procedures for structural valve deterioration. However, multiple procedural and anatomical hurdles remain, limiting its universal applicability and long-term outcomes. Dr. Palmerini began by outlining the major complications associated with ViV, including coronary obstruction, patient–prosthesis mismatch (PPM), and anatomical difficulties associated with sutureless or stentless valves. He also highlighted concerns regarding valve-related embolic debris, durability, optimal antithrombotic therapy, and the comparative safety and efficacy of TAVR versus redo surgery (Figure 1). Figure 1. Current Problems with ViV Procedure Among these, coronary obstruction remains one of the most feared complications, particularly due to sinus sequestration or leaflet displacement toward the coronary ostia. Dr. Palmerini detailed protective strategies such as CHIMNEY stenting, BASILICA, and emphasized that newer technologies like the short cut device may offer more reliable protection in the future—personally stating he finds it especially promising. Another major focus was on patient–prosthesis mismatch, which affects over half of ViV patients according to STS and TVT registry data. Dr. Palmerini stressed the value of bioprosthetic valve fracture (BVF) as a key technique for the successful procedure. He devoted significant time to describing the mechanics, timing, and safety profile of BVF, citing both registry data and multicenter experiences. Importantly, delayed BVF—performed after valve implantation—was associated with lower residual gradients and better hemodynamic outcomes. Issues surrounding sutureless and stentless valves were also addressed, particularly the anatomical ambiguity they present in identifying landing zones and achieving adequate anchoring. These factors contribute to higher procedural failure rates, as noted in the VIVID registry. In conclusion, Dr. Palmerini emphasized that while ViV TAVR is generally safe and effective, procedure planning, device selection, and operator technique are crucial to optimizing outcomes. He called for randomized controlled trials, especially in intermediate-risk patients aged 70–80 years, to better define long-term strategies for ViV management. TAVR: Current Status and Future Perspective Saturday, April 26, 9:50 AM-11:20 AM Coronary Theater, Level 1 Check The Session

May 16, 2025 551

TCTAP 2025

Lessons Learned from EARLY TAVR Trial

Philippe Généreux Morristown Medical Center, USA At TCTAP 2025, during the “TAVR: Current Status and Future Perspective” session held on April 26 in the Coronary Theater, Dr. Philippe Généreux (Morristown Medical Center, USA) presented pivotal findings from the EARLY TAVR trial, a prospective, multicenter randomized controlled trial that challenges the conventional wait-for-symptoms approach in patients with asymptomatic severe aortic stenosis (AS). The study enrolled 1,578 patients, ultimately randomizing 901 asymptomatic individuals aged ≥65 years with severe AS, preserved LVEF (≥50%), and an STS score ≤10% (Figure 1). Asymptomatic status was confirmed via negative treadmill stress testing, or, when not feasible, by detailed clinical history. Participants were randomized 1:1 to early transfemoral TAVR (using SAPIEN 3 or SAPIEN 3 Ultra) versus clinical surveillance (CS). Figure 1. Study design The primary endpoint was a composite of all-cause death, any stroke, or unplanned cardiovascular hospitalization. After a median follow-up of 3.8 years, the event rate was significantly lower in the TAVR group (35.1%) compared to CS (51.2%) with a hazard ratio of 0.50 [95% CI: 0.40–0.63], p < 0.001 (Figure 2). Notably, this translates into a number needed to treat (NNT) of ~6 at 2 years, highlighting the tangible benefit of early intervention. Figure 2. Primary Endpoint Although all-cause mortality alone did not significantly differ (HR 0.93, p = 0.74), the lower rates of unplanned cardiovascular events and stroke underscore the importance of timely aortic valve replacement. Moreover, nearly half of patients initially managed with CS required AVR within one year, with a large proportion presenting with advanced symptoms or acute valve syndromes, which are associated with worse procedural and clinical outcomes. Dr. Généreux emphasized that early referral and structured planning for TAVR should be considered even in asymptomatic patients. “There is no penalty to early TAVR,” he stated, reinforcing that delayed intervention may increase the risk of irreversible cardiac damage or stroke. In summary, the EARLY TAVR trial offers robust evidence supporting a proactive treatment strategy for asymptomatic severe AS, redefining clinical practice toward earlier and safer intervention with transcatheter valve therapy. TAVR: Current Status and Future Perspective Saturday, April 26, 9:50 AM-11:20 AM Coronary Theater, Level 1 Check The Session

May 16, 2025 455

TCTAP 2025

Dr. Do-Yoon Kang Highlights TEER as a Promising Strategy in Atrial Functional MR

Do-Yoon Kang Asan Medical Center, Korea (Republic of) At the TCTAP 2025 Live Case & Lecture Session 8 held on April 25 in the Valve & Endovascular Theater, Dr. Do-Yoon Kang from Asan Medical Center delivered a highly anticipated featured lecture on the evolving role of transcatheter edge-to-edge repair (TEER) in atrial functional mitral regurgitation (AFMR), a subtype of functional mitral regurgitation (FMR) gaining growing clinical attention. Titled "TEER for Atrial Functional MR: Evidence and Future Perspectives," the presentation provided a comprehensive synthesis of pathophysiological insights, procedural outcomes, and emerging clinical data that underscore TEER's role in the treatment algorithm for this complex entity. Dr. Kang opened by distinguishing atrial functional MR from the classic ventricular subtype, emphasizing that AFMR is primarily driven by isolated mitral annular dilation, left atrial enlargement, and insufficient leaflet remodeling—often in the setting of long-standing atrial fibrillation. "Atrial functional MR represents a distinct pathophysiologic mechanism. Unlike ventricular FMR, left ventricular systolic function is preserved and annular dynamics are the central driver," Dr. Kang explained, citing foundational echocardiographic data from Asan Medical Center and international registries. Referencing a 2019 Asan cohort, Dr. Kang noted that moderate or greater AFMR was present in 1.8% of atrial fibrillation patients. The structural profile of these patients typically includes preserved left ventricular ejection fraction (LVEF ≥ 60%), normal indexed left ventricular (LV) volume, and significant left atrial enlargement—findings that are now central to the proposed diagnostic criteria published by Zoghbi et al. in 2022. The lecture moved swiftly into therapeutic strategies, where Dr. Kang addressed the limitations of both surgical intervention and conservative management. "Surgical outcomes in AFMR remain suboptimal due to older patient age, high comorbidity burden, and relatively preserved ventricular function," he explained, citing data from Cleveland Clinic and multicenter observational series. Notably, surgical mitral repair or replacement in AFMR patients was associated with high mortality and recurrent heart failure hospitalization. Against this backdrop, TEER has emerged as a non-surgical alternative for high-risk patients. Dr. Kang presented data from the Global EXPAND registry, MITRA-TUNE trial, and Asan Medical Center's (AMC) own experience. In MITRA-TUNE, which enrolled patients with preserved EF and minimal ventricular dilation, TEER achieved an 83% procedural success rate. The study reported 2% in-hospital mortality and 5% mortality at 30 days. At two years, combined all-cause mortality and heart failure hospitalization exceeded 40%, underscoring the high-risk nature of this population—but also demonstrating that TEER could offer clinical benefit in a subset of carefully selected patients. Outcomes from AMC mirrored these findings. Immediate post-TEER echocardiography showed marked reductions in MR severity and promising one-year follow-up data, including symptomatic improvement. However, Dr. Kang remained cautious, emphasizing the limitations of existing studies. "Registry-based evidence is encouraging but plagued by small sample sizes, heterogeneous definitions, and inconsistent inclusion criteria," he noted. Looking forward, Dr. Kang highlighted ongoing efforts to standardize AFMR classification and expand the evidence base through an international registry led by Mayo Clinic. This multi-center retrospective study involving centers from the U.S., Europe, and Korea aims to compare TEER against conservative management in terms of mortality, heart failure hospitalization, and symptomatic improvement at one year. In his closing remarks, Dr. Kang offered a tempered optimism: "Atrial functional MR is a unique clinical entity that deserves a tailored approach. TEER is emerging as a valuable option for patients who are poor surgical candidates, but we need robust randomized data to define its role definitively." The session reinforced the notion that while AFMR remains a diagnostic and therapeutic frontier, evolving imaging definitions and procedural strategies like TEER are poised to change the clinical landscape—offering hope for a patient population with limited therapeutic options—pending the validation of ongoing clinical trials. Live Case & Lecture 8: Mitral TEER Friday, April 25, 8:30 AM-9:27 AM Valve & Endovascular Theater, Level 1 Check The Session

May 09, 2025 755

TCTAP 2025

Dr. Sripal Bangalore Recalibrates the Post-ISCHEMIA Era: Guideline-Driven Revascularization in Left ...

Sripal Bangalore New York University Grossman School of Medicine, USA At the TCTAP 2025 Workshop Session held on April 25, titled "Management of Ischemic Heart Disease 2025: ISCHEMIA Trial Has Been a Major Inescapable Turning Point", Sripal Bangalore, MD, MHA, from NYU Grossman School of Medicine, delivered a thought-provoking lecture that redefined the strategic role of revascularization in patients with stable ischemic heart disease (SIHD), particularly those with left main coronary artery disease (LM) and three-vessel coronary artery disease (3VD). Dr. Bangalore meticulously synthesized long-term trial data and updated guideline recommendations, emphasizing a precision-based approach to coronary revascularization that bridges historical lessons and future clinical demands. "The ISCHEMIA trial fundamentally changed how we view revascularization in SIHD," he began, referring to the landmark study which demonstrated no overall mortality benefit of an initial invasive strategy over optimal medical therapy (OMT) in the general SIHD population. According to 7-year follow-up data from ISCHEMIA EXTEND, all-cause mortality remained statistically neutral between the invasive and conservative arms—13.4% versus 12.7%, respectively (HR [hazard ratio] 1.00; 95% CI, 0.85–1.18; p = 0.741). However, Dr. Bangalore cautioned against a monolithic interpretation of these results. "The nuance lies in the subgroups," he asserted. "Patients with left main disease or 3VD—especially those with impaired left ventricular function—may still derive substantial benefit from revascularization, particularly surgical revascularization." Dr. Bangalore reinforced this point with historical and contemporary evidence. He cited data from Yusuf et al. (1994) and modern subgroup analyses showing that CABG continues to offer a survival benefit in high-risk anatomic subsets. In left main disease, particularly in patients with reduced ejection fraction and severe symptoms, CABG consistently outperforms medical therapy alone. "We must not lose sight of what we've learned over decades of clinical trials," he said. "Revascularization isn't obsolete—it simply needs to be better targeted." Beyond survival, the session emphasized quality of life as a key clinical endpoint. Drawing from Seattle Angina Questionnaire (SAQ) data within the ISCHEMIA trial, Dr. Bangalore showed that patients with angina experienced significantly better symptom relief and quality-of-life improvements with revascularization, particularly when complete revascularization was achieved. "In asymptomatic patients, the benefit is minimal," he noted. "However, for those with persistent angina, revascularization provides not just relief—but durability." Moreover, data from the FAME 2 (Fractional Flow Reserve versus Angiography for Multivessel Evaluation 2) trial and post-hoc ISCHEMIA analyses indicated that invasive strategies meaningfully reduced spontaneous myocardial infarctions and unplanned hospitalizations for unstable angina, resulting in a significant reduction in cardiovascular stays (685 vs. 1,095 days alive out of hospital, p < 0.001). "Morbidity reduction is an often-overlooked but critical endpoint," Dr. Bangalore emphasized. "Patients may not live longer, but they certainly live better." Turning to clinical practice guidelines, Dr. Bangalore highlighted the evolving stances of major societies. The 2021 ACC/AHA Revascularization Guidelines recommend CABG in SIHD patients with normal ejection fraction and left main disease to improve survival. In 3VD, CABG is considered reasonable, whereas the survival benefit of PCI remains uncertain. Meanwhile, the 2024 ESC Guidelines for the Management of Chronic Coronary Syndromes offer a more nuanced classification, granting PCI a role in patients with low anatomical complexity and preserved ejection fraction. "We're moving toward more individualized algorithms," he explained. "Revascularization decisions should now integrate anatomy, physiology, symptoms, and patient preference." Risk stratification tools such as the SYNTAX score play an increasingly important role in these individualized decisions. In closing, Dr. Bangalore urged a paradigm shift: from an all-or-nothing approach to a risk-calibrated, patient-centered model. "The future of revascularization is not about choosing between PCI and CABG, or even between medicine and intervention," he concluded. "It's about identifying the right patients, for the right therapy, at the right time—using evidence as our compass, and the patient's life as our guide." Dr. Bangalore's session not only reframed the implications of ISCHEMIA, but also charted a forward-looking course for clinicians managing complex coronary disease in the post-ISCHEMIA era. His message was clear: revascularization still has a vital role—but only when it's precision-guided, incorporating anatomical complexity scores, functional assessments, and comprehensive patient evaluations. Management of Ischemic Heart Disease 2025: ISCHEMIA Trial Has Been a Major Inescapable Turning Point Thursday, April 24, 8:10 AM-9:40 AM Coronary Theater, Level 1 Check The Session

May 09, 2025 616

TCTAP 2025

Preparing Second Attempt for Previous Failed CTO PCI

Jung-Kyu Han Seoul National University Hospital, Korea (Republic of) Chronic total occlusion percutaneous coronary intervention (CTO PCI) remains one of interventional cardiology's most technically challenging procedures. Despite advancements in crossing devices, microcatheters, and guidewires, initial procedural failure rates range from 10-40%, depending on operator experience and lesion complexity. However, evidence suggests that a carefully planned second attempt can achieve successful revascularization in approximately 50-70% of previously failed cases when appropriate patient selection, optimal timing, and technical modifications are implemented. Patient Selection: Evidence-Based Clinical Criteria Selecting patients for reattempted CTO PCI requires objective measures of myocardial ischemia and symptoms. Optimal candidates include those with Canadian Cardiovascular Society (CCS) angina class ≥2 despite optimal medical therapy. On stress imaging, patients should also have objective evidence of myocardial ischemia (>10% of left ventricular mass). In addition, myocardial viability should be confirmed by cardiac MRI, PET, or dobutamine echocardiography. The best candidates have occlusions in prognostically significant territories, such as the proximal LAD, large dominant RCA, or last remaining patent vessel. Retrospective analyses have shown that successful CTO revascularization in these patients significantly improved angina symptoms (Seattle Angina Questionnaire scores) and reduced major adverse cardiac events (MACE) at 12-24 months. Therapeutic Window: Pathophysiological Considerations The optimal timing for a second attempt is within 60-90 days after the initial failure. This interval allows for the resolution of procedure-induced vascular inflammation (7-14 days), remodeling of dissection planes from initial wiring attempts (30-45 days), and stabilization of plaque architecture before excessive fibrotic reorganization (>90 days). A study by Zhong et al. (JACC Intv. 2022) demonstrated that reattempted procedures performed within the optimal therapeutic window of 60-90 days achieved a significantly higher success rate with an odds ratio of 0.85 per 90 day increment (95% CI: 0.73-0.98). Advanced Imaging CT coronary angiography with dedicated CTO protocols can provide critical information on the three-dimensional course of the occluded segment, calcium burden quantification, side branch anatomy at the proximal and distal caps, and the size and quality of potential collateral channels. Intravascular ultrasound (IVUS) guidance significantly enhances procedural success during reattempts. This includes precise identification of proximal cap microanatomy (e.g., calcium arc thickness), confirmation of true lumen versus subintimal wire position, guided re-entry from subintimal space to true lumen, and optimization of stent sizing and expansion. Technical Modifications: Lesion-Specific Approach The procedural strategy for a second attempt should be tailored based on the failure mode encountered during the initial attempt. For proximal cap penetration failures, advancement to higher gram-force wires (12-30 g), rotational atherectomy for calcified caps, and "scratch-and-go" techniques with stiff guidewires or dedicated CTO devices are recommended. In cases of wire propagation failures, implementation of advanced algorithms such as STAR, mini-STAR, or LAST technique, along with parallel wire technique using microcatheters to optimize wire position, can be beneficial. For distal cap re-entry failures, retrograde approaches via septal or epicardial collaterals for complex lesions (J-CTO score ≥3), reverse CART technique with appropriately sized balloons, and use of dedicated re-entry devices like the Stingray™ system for challenging anatomies are appropriate strategies. When equipment delivery failure occurs, enhanced guide catheter support techniques and anchor balloon techniques can improve device delivery. Complication Avoidance Strategies Second-attempt CTO PCI must incorporate enhanced safety protocols to minimize complications. These include radiation dose minimization techniques (15 frames/second fluoroscopy, collimation), stage-wise contrast volume limitations (10%), persistent angina symptoms despite optimal medical therapy, and preserved viability in the target vessel territory. As dedicated CTO equipment continues to evolve, hybrid algorithms are refined, and operator expertise grows in specialized CTO centers, outcomes for this challenging subset of coronary interventions are expected to improve further. Prospective randomized trials evaluating staged hybrid approaches and novel crossing technologies will be essential to establish definitive, evidence-based protocols for reattempted CTO interventions. CTO PCI Technical Forum: Learn From Masters Friday, April 25, 3:10 PM-4:40 PM Presentation Room 1, Level 1 Check The Session

April 25, 2025 523

TCTAP 2025

Selection of the Appropriate Atherectomy Device for Coronary Calcium

Ajay J. Kirtane Columbia University Medical Center, USA Seoul, April 2025 – In his upcoming TCTAP 2025 presentation, Dr. Ajay J. Kirtane, MD (Columbia University Irving Medical Center) will highlight the complexities of treating heavily calcified coronary lesions and the evolving role of advanced calcium modification strategies. Heavily calcified lesions, observed in over half of patients in the SYNTAX trial, are a major predictor of adverse procedural and clinical outcomes. Dr. Kirtane highlights that calcium leads to impaired stent delivery, under-expansion, malapposition, and increased risks of dissection, perforation, restenosis, and stent thrombosis. Data from TWENTE and DUTCH PEERS studies further confirm that severe calcification is associated with higher rates of target vessel failure (TVF) and definite stent thrombosis at two years. Figure 1. Despite growing enthusiasm for advanced devices like orbital atherectomy and intravascular lithotripsy (IVL), the ECLIPSE trial yielded insights. The study compared orbital atherectomy to conventional balloon angioplasty prior to DES implantation in severely calcified lesions. Results showed no significant difference in procedural success or minimum stent area (MSA), and the primary clinical endpoint—1-year TVF—was also statistically similar. However, according to Dr. Kirtane, the takeaway is not that atherectomy failed; balloon—based approaches worked far better than expected. Figure 2. Dr. Kirtane would advocate a stepwise image-guided approach to lesion preparation. For lesions that are long, heavily calcified, and cannot be crossed by balloon, pre-arterectomy and imaging are required to confirm adequate preparation. Images should be re-reviewed to confirm calcium fracture, even for lesions that can be crossed by a balloon. In summary, "The success of PCI in calcified lesions is not a matter of device, but of strategy and precision, and that begins with imaging." Managing Coronary Calcium: Insights and Approaches Saturday, April 26, 8:30 AM-9:40 AM Coronary Theater, Level 1 Check The Session

April 25, 2025 420

TCTAP 2025

Rule of 6-8-12 for Left Main Upfront 2-Stenting

Jung-Min Ahn Asan Medical Center, Korea (Republic of) At the TCTAP 2025 Hot Topics session, Professor Jung-Min Ahn of Asan Medical Center presented a transformative lecture titled “Rule of 6-8-11 for Left Main Upfront 2-Stenting,” unveiling a novel, intravascular ultrasound (IVUS)-based framework to guide percutaneous coronary intervention (PCI) in unprotected left main (LM) bifurcation disease. Drawing on a wealth of institutional experience bolstered by new long-term data, Prof. Ahn proposed the “6-8-11” rule—a clinically validated evolution of the earlier “5-6-7-8” guideline. He began by tracing the evolution of LM revascularization from coronary artery bypass grafting (CABG) to PCI, referencing key evidence from the MAIN-COMPARE registry and the 10-year results of the PRECOMBAT trial. These findings, showing comparable mortality between PCI and CABG, have redefined the role of PCI in complex LM anatomy. Prof. Ahn then shifted focus to what he termed the “next frontier” in LM intervention: optimization through imaging-defined minimal stent area (MSA). Citing long-term data, including recently published findings in Circulation: Cardiovascular Interventions (2024), he demonstrated that IVUS-derived MSAs at three critical segments—the distal LM, left anterior descending (LAD) ostium, and left circumflex (LCX) ostium—are linearly correlated with the risk of major adverse cardiac events (MACE) over five years. Specifically, under-expansion below 11.8 mm² in the distal LM, 8.3 mm² in the LAD ostium, and 5.7 mm² in the LCX ostium was significantly associated with increased long-term risk. In contrast, the simplified “5-6-7-8” thresholds demonstrated limited prognostic discrimination. These findings, Prof. Ahn argued, underscore the need to move beyond angiographic benchmarks toward outcome-driven, segment-specific targets—the foundation of the “6-8-11” rule. Turning to real-world application, Prof. Ahn outlined how these targets can be systematically incorporated into contemporary two-stent strategies, particularly in crush and DK-crush techniques. He emphasized that achieving ≥8 mm² in the LAD ostium and ≥6 mm² in the LCX ostium should not be aspirational but mandatory procedural endpoints. Failure to meet these thresholds, he warned, may predispose patients to ischemic complications, target lesion revascularization, or mortality. “IVUS-first, optimize always,” he declared, advocating a fundamental shift in operator mindset. Adding further weight to the argument, Prof. Ahn presented newly analyzed data from 829 patients who underwent IVUS-guided single-stent crossover LM PCI at Asan Medical Center. The analysis identified optimal MSA cutoffs of 11.4 mm² for the proximal LM, 8.4 mm² for the distal LM, and 8.1 mm² for the LAD ostium in predicting 5-year MACE. Notably, under-expansion in the proximal LM was associated with an almost twofold increase in adverse events. In contrast, simultaneous under-expansion in the distal LM and LAD ostium conferred even higher risk. These results reinforce the critical value of segment-specific MSA targets and validate IVUS as a tool for imaging and precision-guided intervention. Prof. Ahn concluded with a compelling message: “It is not enough to simply implant a stent. What matters is how well you implant it.” He emphasized that imaging alone does not improve outcomes unless used to guide optimization. He proposed that the “6-8-11” rule offers a simple yet evidence-based algorithm to elevate the standard of care in LM bifurcation PCI. As bifurcation strategies grow more sophisticated, Prof. Ahn’s lecture served both as a synthesis of state-of-the-art data and a challenge to the interventional community: to abandon outdated thresholds and embrace a new era of precision PCI. Anchored in long-term clinical outcomes, the “6-8-11” rule is poised to become a cornerstone of modern LM revascularization. Figure. New IVUS MSA for LM Bifurcation Stenting Bifurcation PCI: New Concept and Approaches Friday, April 25, 2:00 PM-4:00 PM Presentation Room 2, Level 1 Check The Session

April 25, 2025 399

TCTAP 2025

Temporal Decoupling Ischemic and Bleeding Risks After Complex PCI; TAILORED-CHIP Trial and Others

Duk-Woo Park Asan Medical Center, Korea (Republic of) On April 25th, a TAILORED-CHIP trial, a new antiplatelet approach tailored to patients undergoing complex percutaneous coronary intervention (PCI), will be presented by Duk-Woo Park, MD, PhD (Asan Medical Center, Ulsan University College of Medicine, Seoul, Republic of Korea). The primary result will be reported in late 2025. Why It Will Matter Patients receiving complex, high-risk PCI—such as left main disease, multivessel stenting, or chronic total occlusions—will continue to face a dilemma: early thrombotic risk and late bleeding risk. Conventional DAPT protocols will no longer suffice, as they treat both phases equally. The TAILORED-CHIP trial will provide a new roadmap: - Early escalation (0-6 months): Stronger antiplatelet agents with low dose ticagrelor (60 mg twice daily) plus aspirin to reduce ischemic events - Late de-escalation (after 6 months): Shift to clopidogrel monotherapy to reduce bleeding events The Trial That Will Shift Guidelines TAILORED-CHIP, a multicenter prospective trial, will show that this temporal modulation approach will lower net adverse clinical events, including both major ischemic and bleeding outcomes. The results of this study will be adopted in future European and American guidelines. Expert View “We will finally be treating patients according to their real-time risk—this is what personalized medicine looks like,” says Dr. Duk-Woo Park, principal investigator of the trial. Other cardiologists will echo this sentiment, calling the strategy “practical and overdue.” What Patients and Hospitals Will Expect The future antiplatelet treatment will not only improve outcomes but also enhance patient adherence, reduce drug-related complications, and optimize healthcare costs. Quick Overview Key Feature TAILORED-CHIP Protocol Time Frame 0-6 months (intensified), >6 months (de-escalated) Goal Reduce both thrombotic and bleeding risks Population High-risk complex PCI patients (Left main, chronic total occlusion, muti-vessel PCI) or high clinical risk (diabetes, chronic kidney disease, EF < 40%) Total 2,000 patients Primary Endpoint Composite of death, myocardial infarction, stroke, stent thrombosis, urgent revascularization, or clinically relevant bleeding (BARC type 2,3 or 5) This new era of antiplatelet therapy will mark a major shift from rigid protocols to risk-responsive strategies. The TAILORED-CHIP trial will pave the way for safer, smarter post-PCI care. Major Issues on Antiplatelet and Antithrombotic Strategy in 2025: Current Dilemma and Next Perspective Friday, April 25, 10:30 AM-11:50 AM Presentation Room 2, Level 1 Check The Session

April 25, 2025 217

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