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TCTAP 2025

Selection of the Appropriate Atherectomy Device for Coronary Calcium

Seoul, April 2025 – In his upcoming TCTAP 2025 presentation, Ajay J. Kirtane, MD (Columbia University Irving Medical Center, USA), 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. He 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 him, the takeaway is not that atherectomy failed; balloon—based approaches worked far better than expected. Figure 2. He 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 488

TCTAP 2025

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

At the TCTAP 2025 Hot Topics session, Jung-Min Ahn, MD, PhD (Asan Medical Center, Korea), 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, he 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. He then shifted his 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, he 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, he 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, he 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. He 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, his 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 457

TCTAP 2025

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

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, 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,” he said, as the 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 274

TCTAP 2025

Novel Insights of Preventive PCI for Non-flow-limiting Vulnerable Plaques

Seung-Jung Park, MD, PhD Asan Medical Center, Korea A recent PREVENT trial suggests that local modification of vulnerable plaques provides additional efficacy with systemic treatment. This multicenter, open-label, randomized trial enrolled a total of 1,606 patients with non-flow limiting (fractional flow reserve > 0.80) vulnerable coronary plaques identified intracoronary imaging, randomly assigning them to either preventive percutaneous coronary intervention (PCI) plus optimal medical treatment or optimal medical treatment alone. The primary outcome was a composite of death from cardiac cause, target-vessel myocardial infarction, ischemia-driven target-vessel revascularization, or hospitalization for unstable or progressive angina at 2 years (Figure 1). Figure 1. In the PREVENT trial, local preventive PCI combined with optimal medical treatment results in a lower incidence of major adverse cardiac events compared with OMT alone in patients with non-flow limiting vulnerable plaques (Figure 2). These findings are particularly significant in lesions with a higher degree of angiographic diameter stenosis (DS, DS ≥ 55%) and lipid-rich plaques (maxLCBI4mm>315). Preventive PCI using current drug-eluting stents is sufficient to reduce the primary composite outcomes. Although bioresorbable vascular scaffolds demonstrate a significant preventive effect at 2 years, this benefit diminishes during long-term follow-up. Concomitant preventive PCI for non-target vessel PCI may improve short- and long-term clinical outcomes (Figure 3). Figure 2. Figure 3. These key findings provide novel insights into the potential benefits of preventive PCI for non-flow-limiting vulnerable plaques. The addition of PCI to optimal medical therapy significantly reduces major adverse cardiac events, particularly in patients with high-risk plaque features. The effectiveness of preventive PCI is further enhanced by careful patient selection based on imaging and lesion characteristics. These results support a personalized approach to managing coronary artery disease beyond traditional flow-based assessments. Vulnerable Plaque Treatment 2025 Friday, April 25, 10:00 AM-11:20 AM Coronary Theater, Level 1 Check The Session

April 25, 2025 323

TCTAP 2025

Interventional Cardiology at Crossroads: A Bright Future of Collaboration; From Intervention to Prev...

As the recipient of the 15th TCTAP Master of the Masters Award, Roxana Mehran, MD (Icahn School of Medicine at Mount Sinai, USA), delivered a message on the transformative future of interventional cardiology—one defined not only by technical excellence in the cath lab but also by long-term, personalized prevention and cross-disciplinary collaboration. Despite significant declines in coronary artery disease (CAD) and myocardial infarction (MI) mortality over the past two decades (Figure 1), cardiovascular disease remained the leading global cause of death. Figure 1. Declining mortality trends in CAD and MI (2000-2025), reflecting gains through procedural, pharmacological, and preventive approaches. Residual Risk: The Next Frontier Post-PCI patients often face continued risk despite successful revascularization. These residual risks fall into three main categories—thrombotic, inflammatory, and metabolic. Thrombotic risk will demand precision beyond standard dual antiplatelet therapy (DAPT). AI-guided tools and individualized strategies will help balance bleeding and ischemic profiles. Novel anticoagulants targeting Factor XI may offer effective protection with lower bleeding risk. Inflammatory risk will gain prominence as trials such as CANTOS and ARTEMIS reinforce the role of cytokines in atherothrombosis. High-sensitivity CRP will guide risk assessment, and therapies targeting IL-1β and IL-6 will likely be integrated into long-term management of high-risk patients. Metabolic risk will remain multifaceted. LDL-C will continue as a key target, with inclisiran and PCSK9 inhibitors offering sustained control. A new focus on lipoprotein(a) will emerge with RNA-based therapies under investigation in the HORIZON and OCEAN(a) trials. The role of metabolic agents—such as SGLT2 inhibitors, GLP-1 receptor agonists, and tirzepatide—will expand significantly, demonstrating cardiovascular benefits even in non-diabetic populations. Imaging-Driven Precision Future care will rely heavily on advanced imaging for diagnosis and treatment planning. Intravascular ultrasound (IVUS) and optical coherence tomography (OCT) will be standard in PCI for optimizing outcomes. Non-invasive tools will enable comprehensive anatomical and functional evaluation, especially coronary CT angiography (CCTA) combined with CT-derived fractional flow reserve (FFR). AI-powered plaque characterization and emerging biomarkers like perivascular fat attenuation—validated in the ORPHAN study—will support early identification of vascular inflammation and risk stratification (Figure 2). Figure 2. AI-enhanced CCTA and perivascular fat attenuation imaging will advance personalized risk prediction and early intervention. Redefining the Interventionalist’s Role As the field evolves, interventional cardiologists will take on expanded roles—leading in acute care and long-term cardiovascular prevention. Armed with next-generation therapeutics, advanced imaging, and digital tools, they will deliver care that is as much preventive as it is interventional. This new model defines success by restoring coronary patency, reducing future events, and improving long-term outcomes—ensuring patients leave the hospital with an open artery and a personalized strategy for lifelong cardiovascular health. 15th TCTAP Master of the Masters Award Thursday, April 24, 11:10 AM-11:35 AM Main Arena, Level 3 Check The Session

April 25, 2025 270

TCTAP 2025

[New RCTs from AMC] Antithrombotic Therapy for AF and CAD: EPIC-CAD Trial and More

Min Soo Cho, MD Asan Medical Center, Korea In patients with coronary artery disease (CAD), the prevalence of atrial fibrillation (AF) is significantly high. However, optimal antithrombotic therapy for managing both conditions is challenging. Previous clinical trials suggested the preferred use of direct oral anticoagulants (DOAC) and dual antithrombotic therapy (DOAC + clopidogrel), followed by the short-term use of triple therapy (DOAC + dual antiplatelet). However, beyond the first year, there remains limited evidence regarding the best long-term management strategy, especially in patients with stable CAD and AF. The EPIC-CAD trial, presented at ESC 2024 and published in the New England Journal of Medicine, tested the hypothesis that standard-dose Edoxaban monotherapy would be superior to dual antithrombotic therapy (Edoxaban plus a single antiplatelet agent) in terms of the primary net clinical outcome in patients with high-risk AF (CHA2DS2-VASc score ≥2) and stable CAD (for those with prior revascularization: ≥12 months for acute coronary syndrome and ≥6 months for chronic CAD; for those on medical therapy only: coronary artery stenosis ≥50%). The primary endpoint was a composite of all-cause mortality, stroke, systemic embolism, myocardial infarction, unplanned revascularization, and major or clinically relevant non-major bleeding at 12 months. (Figure 1) Figure 1. 1,040 patients were randomized 1:1 to receive either Edoxaban monotherapy (60 mg or 30 mg based on dose-reduction criteria) or dual antithrombotic therapy. The mean age was 72, 22% were women; the mean CHA2DS2-VASc and HAS-BLED scores were 4.3 and 2.1, and 66% had undergone previous revascularization. At 12 months, Edoxaban monotherapy significantly reduced the risk of the primary endpoint by 56% compared to dual antithrombotic therapy (6.8% vs. 16.2%; hazard ratio [HR] 0.44; 95% confidence interval [CI] 0.30-0.65; p

April 24, 2025 369

TCTAP 2025

[New RCTs from AMC] Most Updated Perioperative Antiplatelet Strategy Post-PCI: ASSURE-DES and More

Jung-Min Ahn, MD, PhD Asan Medical Center, Korea The management of antiplatelet therapy in patients who need non-cardiac surgery after percutaneous coronary intervention (PCI) with drug-eluting stents (DES) requires consideration, including the risk of stent thrombosis with cessation and bleeding with continuation. Despite current guidelines recommending the continuation of aspirin perioperatively if the bleeding risk allows, there is limited data on the continuation of aspirin in patients with prior PCI with DES who are undergoing non-cardiac surgery. In subgroup analysis of the POISE-2 trial, continuation of aspirin in patients with prior PCI reduced the risk of death or non-fatal myocardial infarction (MI) (hazard ratio [HR] 0.50; 95% confidence interval [CI] 0.26-0.95). Perioperative Antiplatelet Therapy in Patients With Drug-Eluting Stent Undergoing Non-cardiac SURgEry (ASSURE-DES) trial is an investigator-initiated, prospective, multicenter, randomized controlled trial comparing the safety and efficacy of aspirin cessation or continuation in the perioperative period of non-cardiac surgery in patients who have undergone PCI with DES for more than 12 months (Figure 1,2). Key exclusion criteria include recent acute coronary syndrome (ACS) (within 1 month), severe left ventricular dysfunction (EF ≤ 30%), severe valvular heart disease, emergent operation, or high bleeding risk operation (e.g., intracranial, intraspinal, or retinal surgery). The primary endpoint was a composite of all-cause death, stent thrombosis, MI, and stroke from 5 days before to 30 days after surgery. Figure 1. Figure 2. A total of 1,010 patients were randomized. Among 926 patients in the modified intention-to-treat population, the primary composite outcome occurred in 3 patients (0.6%) in the aspirin monotherapy group and 4 patients (0.9%) in the no antiplatelet group (difference, -0.2 percentage points; 95% CI: -1.3 to 0.9; p > 0.99) (Figure 3). There was no stent thrombosis in either group. The incidence of major bleeding did not differ significantly between groups (6.5% vs. 5.2%; p = 0.39), whereas minor bleeding was significantly more frequent in the aspirin group (14.9% vs. 10.1%; p = 0.027) (Figure 4). Figure 3. Figure 4. In conclusion, withholding antiplatelet therapy for 5 days before surgery may be a safe alternative to continuing aspirin in this patient population, especially when undergoing lower-risk procedures. While the event rates were low, and the study was underpowered to detect slight differences, these results could inform more flexible perioperative management strategies in future clinical practice. Best and Novel Medical Therapy in Interventional Cardiology: What Are New in 2025? Thursday, April 24, 3:30 PM - 5:00 PM Presentation Room 2, Level 1 Check The Session

April 24, 2025 331

TCTAP 2025

AI in Coronary Imaging: On the Brink of Mainstream Adoption

Artificial intelligence (AI) is rapidly redefining the landscape of cardiovascular medicine, particularly in coronary imaging. As it evolves from a niche innovation to a potentially mainstream tool, its role in enhancing image acquisition, interpretation, and individualized treatment planning continues to expand. In an upcoming session at TCTAP 2025 titled "AI in Coronary Imaging: Mainstream or a Niche Research Tool?" Bon-Kwon Koo, MD, PhD (Seoul National University Hospital, Korea), will provide insight into the transformative impact of AI on invasive and non-invasive coronary imaging modalities. In recent years, AI—especially through machine learning (ML) and deep learning (DL)—has emerged as a critical adjunct in coronary imaging. Its applications span multiple domains, from optimizing image quality to automating lesion assessment and even simulating physiology from image data. AI's integration into imaging workflows has become mainstream in several aspects, such as artifact reduction and automated segmentation. A notable example of AI's clinical utility is seen in the EMERALD II study, where AI-enabled Quantitative Coronary Plaque and Hemodynamic Analysis (AI-QCPHA) demonstrated superior predictive value for future acute coronary syndromes compared to conventional imaging analysis (Figure 1). Figure 1. Such tools offer clinicians improved risk stratification and data-driven support for treatment decisions. Another emerging application is the use of explainable machine learning methods that analyze lesion-specific data, enabling precision risk prediction and tailored treatment strategies for individual patients. Figure 2. However, despite these encouraging advancements, several challenges persist before AI can be fully integrated into everyday clinical practice. AI models depend heavily on large, diverse, and high-quality datasets. Their generalizability across different patient populations and imaging protocols remains a concern. Furthermore, the lack of standardization and the complexity of regulatory pathways pose significant hurdles. Prospective validation in multicenter, real-world settings is critical. Moreover, achieving regulatory clarity and developing user-friendly interfaces will determine how quickly and effectively AI can transition from academic research to routine bedside use. He emphasizes the importance of cross-disciplinary collaboration—among clinicians, engineers, and regulatory agencies—to guide the responsible deployment of AI in coronary imaging. He notes that with ongoing validation studies and regulatory adaptation, AI is poised to become an indispensable adjunct in cardiovascular diagnostics. As this technological frontier advances, TCTAP 2025 attendees will gain valuable foresight into the promise and limitations of AI in coronary imaging and how it might soon shape the future of cardiovascular care. MedTech Innovation Thursday, April 24, 3:20 PM - 4:30 PM Valve & Endovascular Theater, Level 1 Check The Session

April 24, 2025 306

TCTAP 2025

DM and Three-Vessel Disease: Why We Need New RCTS- DEFINE-DM Trial

At TCTAP 2025, Duk-Woo Park, MD, PhD (Asan Medical Center, Korea), will present an important lecture titled “DM and Three-Vessel Disease: Why We Need New RCTs-DEFINE-DM Trial.” His presentation will highlight a bold initiative to redefine the revascularization strategy for diabetic patients with multivessel coronary artery disease (CAD) through a rigorously designed trial incorporating contemporary interventional advances. Why DEFINE-DM Is Needed For decades, landmark trials such as FREEDOM, BARI 2D, SYNTAX, and BEST have consistently supported coronary artery bypass grafting (CABG) over percutaneous coronary intervention (PCI) in patients with type 2 diabetes mellitus (T2DM) and multivessel CAD. However, most of these studies were limited by outdated technologies-first generation drug-eluting stents (DES), minimal use of physiologic or intravascular imaging guidance, and lack of contemporary guideline-directed medical therapy (GDMT). He will emphasize that the evolution in interventional cardiology now demands a reassessment. With second generation DES, widespread use of IVUS/OCT and FFR/iFR, and robust cardiovascular and antidiabetic therapies—including SGLT2 inhibitors and GLP-1 receptor agonists—the treatment landscape has transformed. DEFINE-DM will aim to answer whether modern PCI can now stand shoulder to shoulder with CABG in diabetic patients with complex coronary disease. Trial Design and Objectives The DEFINE-DM (Diabetes-Centered Evaluation of Revascularization Strategy of Functional and Imaging-CombiNEd State-of-the-Art Percutaneous Coronary Intervention or Coronary-Artery Bypass Grafting in Patients with Diabetes Mellitus and Multivessel Coronary Artery Disease) trial will be a multicenter, international, randomized controlled trial, powered to test the non-inferiority of PCI compared with CABG. 1,360 patients with T2DM and angiographically confirmed three-vessel CAD (≥50% stenosis in all three major epicardial arteries) will be enrolled, excluding those with left main disease. Patients will be randomized in a 1:1 fashion to either modern PCI or standard CABG, with revascularization decisions made by an independent heart team. The primary endpoint will be a composite of all-cause death, myocardial infarction (MI), or stroke at 2 years. Secondary endpoints will include each component of the primary composite outcome, a composite of death or MI, a composite of death, MI, stroke or repeat revascularization, stent thrombosis, symptomatic graft occlusion or stenosis, bleeding events, and patient-reported outcomes, including quality of life and angina class. Interventions in Each Arm In the PCI arm, lesion selection will be guided by FFR (≤0.80), or adverse imaging features and all procedures will require post-stent optimization using IVUS or OCT. Only second-generation DES will be used. In the CABG arm, surgery will be performed within 30 days of randomization, with internal mammary artery grafting to the LAD and complete revascularization strongly encouraged. He will highlight the strict standardization of procedures across both arms and the protocol’s insistence on contemporary medical therapy. Endocrinology consultations during hospitalization and follow-up will be implemented to ensure optimized diabetic care, including the recommended use of SGLT2 inhibitors or GLP-1 RAs. Eligibility Criteria Participants must be ≥20 years old, have established T2DM, and be deemed suitable for PCI and CABG. Key exclusion criteria will include left main disease, STEMI within 5 days, EF

April 24, 2025 246

TCTAP 2025

Redo-TAVR From Planning to Execution: Tips and Tricks

At TCTAP 2025, Gilbert H. L. Tang, MD (Mount Sinai Health System, USA), will present a comprehensive framework to streamline Redo-TAVR procedures through simplified planning and standardized technical execution. As the number of patients receiving transcatheter aortic valve replacement (TAVR) increases, the need for effective and reproducible strategies for Redo-TAVR becomes crucial, especially in lifetime valve management. In his talk, titled "Redo-TAVR From Planning to Execution: Tips and Tricks," he will share a practical approach that enables operators to safely navigate various TAV-in-TAV scenarios while maintaining optimal hemodynamic outcomes and ensuring coronary access. He will begin by categorizing Redo-TAVR procedures based on the interaction between the index and the second transcatheter heart valve (THV). The four possible combinations include: Short-in-Short, Short-in-Tall, Tall-in-Short, and Tall-in-Tall. This classification sets the stage for further procedural planning by determining the anatomical interaction and associated risks. By simplifying these into two scenarios based on the design of the second valve (TAV #2 – short or tall), he will guide the audience through tailored decision-making pathways. Each combination presents unique challenges related to valve positioning, coronary risk, and THV expansion. The planning process will start with a detailed evaluation of four key anatomical and procedural concepts. First, understanding the fluoroscopic markers and structural landmarks of the existing valve is essential for the successful positioning of TAV #2. Second, the neo-skirt plane (NSP), which represents the new functional skirt level after redo, is determined by the commissural post of the index valve (for tall TAV #2) or the outflow level of TAV #2 (for short TAV #2). Third, the coronary risk plane (CRP), the lowest margin of the coronary orifice, sets the lower boundary of the coronary risk zone (CRZ). Lastly, he will emphasize evaluating the CRZ by measuring the virtual to annulus (VTA) distance, which should ideally be greater than 4 mm to minimize obstruction risk. These concepts will be visualized using frame alignment views on fluoroscopy, offering an intuitive method to identify NSP and CRP for optimal TAV #2 implantation. He will then outline a procedural strategy that translates anatomical insights into actionable techniques, beginning with identifying the index TAV and evaluating the CRZ. Next, he will focus on determining the appropriate implant position for TAV #2, which will depend on its design and the anatomical environment. Pre-dilatation of the index TAV will be highlighted as a critical step, especially in underexpanded or stenotic valves, to optimize the seating of TAV #2 and reduce the risk of HALT. During the implantation of TAV #2, he will recommend slow and controlled deployment to maintain coaxiality and avoid unintended valve movement, particularly in short-in-short or short-in-tall configurations. Post-dilatation will be the final optimization step to ensure adequate expansion of TAV #2, minimize perivalvular leak, and improve overall hemodynamic performance. Throughout the presentation, he will illustrate real-world case examples involving valve pairs, such as SAPIEN 3 Ultra RESILIA, in Evolut PRO or Navitor Vision. He will highlight the importance of coaxial alignment, stiff wire manipulation, and the role of coronary protection in borderline CRZ measurements, such as those with VTA between 2 and 4 mm. He will stress that post-dilatation alone cannot correct underexpanded index valves, reinforcing the importance of aggressive pre-dilatation to optimize long-term outcomes. The proposed Redo-TAVR strategy will also emphasize the value of standardization. With pamobile tools such as the "Redo TAV" app (developed by Vinnie Bapat, Miho Fukui, et al.), operators can access procedural checklists and visualize anatomical landmarks in real-time. By demystifying the Redo-TAVR workflow, he aims to provide a reproducible roadmap that reduces variability in outcomes while ensuring safety across complex anatomical subsets. He will conclude by emphasizing that Redo-TAVR can be simplified through structured planning and meticulous execution. Frame alignment fluoroscopy will be critical to determine NSP and CRP. Pre-dilatation will remain essential for procedural success and long-term valve durability. Positioning of TAV #2 should prioritize coaxiality and depth control, while slow inflation during deployment will reduce the risk of valve migration and coronary obstruction. As Redo-TAVR becomes a more frequent necessity in lifetime valve care, his approach is expected to shape procedural standards and provide clarity for interventional cardiologists navigating this evolving field. Figure 1. NSP and CRZ Evaluation with Frame Alignment View TAVR: Key Issues in 2025 Thursday, April 24, 8:10 AM-9:50 AM Valve & Endovascular Theater, Level 1 Check The Session

April 24, 2025 285

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