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TCTAP 2026

Early Surgery versus Conservative Management for Asymptomatic Severe AS

The management of asymptomatic severe aortic stenosis took center stage at TCTAP 2026, as Duk Hyun Kang, MD, PhD (Asan Medical Center, Korea), presented the final outcomes of the RECOVERY trial during the Late-Breaking Clinical Trials 2026 session. The study, “Early Surgery Versus Conservative Management for Asymptomatic Severe Aortic Stenosis,” showed that early surgical aortic valve replacement provided a significant long-term clinical benefit over conservative management, challenging the traditional watchful-waiting strategy. Watchful waiting had traditionally been recommended for patients with asymptomatic severe aortic stenosis, with prompt intervention once symptoms developed. However, recent clinical trials had challenged the appropriateness of conservative management in this population. The RECOVERY trial was designed to further clarify whether early surgery could provide a sustained long-term benefit compared with conservative care. The RECOVERY trial was a prospective, multicenter, open-label, randomized trial that compared early surgical aortic valve replacement with conservative management in asymptomatic patients with severe aortic stenosis. Severe aortic stenosis was defined as an aortic valve area of 0.75 cm² or less, with a peak aortic jet velocity of 4.5 m/s or higher or a mean transaortic gradient of 50 mmHg or higher. A total of 145 asymptomatic patients with severe aortic stenosis were randomized. Among them, 73 patients were assigned to early surgery and 72 patients were assigned to conservative care. Patients in the early surgery group were scheduled to undergo aortic valve replacement within 2 months after randomization. Patients in the conservative care group were referred for aortic valve replacement if symptoms developed, if left ventricular ejection fraction decreased below 50%, or if peak aortic jet velocity increased by more than 0.5 m/s per year during follow-up. The primary end point was a composite of operative mortality or cardiovascular death during the entire follow-up period. Secondary end points included death from any cause, repeat aortic valve surgery, clinical thromboembolic events, and hospitalization for heart failure. Baseline characteristics were generally well balanced between the two treatment groups. The mean age of the study population was 64 years, and 49% of patients were men. The mean EuroSCORE II was 0.9%, indicating a relatively low operative risk. The mean peak aortic jet velocity was approximately 5.1 m/s, and the most common cause of aortic stenosis was bicuspid aortic valve. In the early surgery group, surgical aortic valve replacement was successfully performed in all patients. There was no operative mortality. In the conservative care group, most patients eventually underwent valve replacement during follow-up, mainly because of symptom development. At 10 years, early surgery significantly reduced the risk of the primary end point compared with conservative management. Operative or cardiovascular death occurred in 2 patients in the early surgery group and in 17 patients in the conservative care group. The hazard ratio for the primary end point was 0.10, indicating a markedly lower risk with early surgery. All-cause mortality was also lower in the early surgery group. Death from any cause occurred in 11 patients in the early surgery group and in 23 patients in the conservative care group. The hazard ratio for all-cause death was 0.42. The cumulative incidence of death from any cause was 11.0% in the early surgery group and 25.0% in the conservative care group at 10 years. Hospitalization for heart failure was less frequent in the early surgery group than in the conservative care group. No patients in the early surgery group were hospitalized for heart failure, whereas 14 patients in the conservative care group experienced heart failure hospitalization during follow-up. The per-protocol analysis yielded results that were consistent with the intention-to-treat analysis. Early surgery continued to show a significant reduction in the primary end point and in death from any cause compared with conservative management. The investigators noted several limitations. The trial used a traditional definition of severe aortic stenosis based on high aortic jet velocity, which could have influenced the risk-benefit balance of early surgery. Exercise testing was selectively performed, and the trial had an open-label design. In addition, the study population consisted of relatively young patients with few comorbidities, which may limit the generalizability of the findings to older or higher-risk patients commonly encountered in real-world practice. In conclusion, the final outcomes of the RECOVERY trial showed that early surgical aortic valve replacement, compared with conservative management, led to a significant reduction in operative or cardiovascular death and death from any cause at 10 years in asymptomatic patients with severe aortic stenosis. These findings suggested that early aortic valve replacement may be a preferred strategy for asymptomatic severe aortic stenosis, particularly in patients with a peak aortic jet velocity of 4.5 m/s or higher. Clinical Science Late-Breaking Clinical Trials 2026 Friday, May 1, 8:30 AM ~ 9:55 AM Presentation Theater 1, Level 1 Watch Session Video

May 28, 2026 329

TCTAP 2026

TMVR vs. Redo-Surgical MVR for Mitral Bioprosthetic Valve Dysfunction

At TCTAP 2026, James D. Flaherty, MD (Northwestern University / Bluhm Cardiovascular Institute, Northwestern Medicine, USA) delivered a comprehensive lecture on the comparative management of failed bioprosthetic mitral valves, contrasting transcatheter mitral valve replacement (TMVR) with redo-surgical mitral valve replacement (redo-SMVR). The lecture reviewed contemporary evidence, clinical trial data, anatomical considerations, and patient selection criteria to guide optimal decision-making in this evolving field. Background Surgical MV repair remained the gold standard for degenerative MR, with 20-year matched survival of 41% vs. 24% for replacement across six centers (Lazam et al., Circulation 2017;135:410–22, n=1,922). When bioprosthetic replacement was required, a meta-analysis of 20 studies (Koulouroudias et al., 2024; n=16,465) showed 40% survival, 79% freedom from reoperation, and 64% freedom from structural valve deterioration (SVD) at 15 years. Most valves lasted more than 10 years, with earlier failure observed in younger patients; bovine pericardial and porcine valves demonstrated comparable long-term durability. Treatment Options for Failed Bioprosthetic Mitral Valves Two principal strategies addressed bioprosthetic mitral valve failure: redo-SMVR and valve-in-valve (VIV) TMVR. The VIV TMVR approach utilized an existing TAVR platform adapted for the mitral position and received FDA approval in June 2017. Initially transapical, the procedure transitioned to a transseptal route — which became quicker and easier with pre-shaped supportive wires. A dedicated Mitral Valve-in-Valve App (developed by Dr. Vinay Bapat) provided anatomical suitability guidance: most bioprosthetic valves and semi-rigid, complete rings were favorable candidates, while rigid or incomplete rings, bands, and elliptical rings were less suitable. Comparative Clinical Outcomes A meta-analysis by Nasir et al. (Int J Cardiol 2024;415:132448; 11 studies, n=11,931) found that VIV TMVR was associated with significantly lower rates of stroke, bleeding, AKI, arrhythmia/AF, and permanent pacemaker implantation compared to redo-SMVR. Redo-SMVR, however, carried lower risk of LVOT obstruction and slightly reduced mitral gradients. Hospital length of stay (LOS) was significantly shorter with VIV TMVR across all included studies (Figure 1). Figure 1. Forest plot showing significantly shorter hospital LOS with VIV TMVR vs. redo-SMVR (Nasir et al., Int J Cardiol 2024; n=11,931). The table below summarizes the key comparative outcomes between the two strategies. Outcome VIV TMVR Redo-SMVR Short-term mortality Lower Higher Stroke Lower ↓ Higher Bleeding / AKI / AF Lower ↓ Higher Permanent pacemaker Lower ↓ Higher LVOT obstruction Higher risk Lower risk ↓ Mitral gradient Slightly higher Slightly lower Hospital LOS Shorter ↓ Longer Table 1. Comparative outcomes of VIV TMVR vs. redo-SMVR (Nasir et al., Int J Cardiol 2024; 11 studies, n=11,931). P3 Mitral VIV Trial The P3 Mitral VIV trial (Malaisrie et al., Circ Cardiovasc Interv 2024;17:e013782) enrolled 50 patients across 12 sites (2018–2021), of whom 32% had predominant MR. Outcomes were excellent: 100% survival, 0% stroke, 0% LVOT obstruction, 0% endocarditis, 0% MV reintervention, and 12% rehospitalization. Hemodynamic improvements were sustained, including significant reductions in MV mean gradient and MVA increase, with meaningful NYHA functional class improvement at follow-up. Neo-LVOT Obstruction: A Critical Anatomical Challenge The primary anatomical barrier specific to TMVR was neo-LVOT obstruction — elongation and narrowing of the LVOT caused by the deflected anterior mitral leaflet (AML). A CT-derived skirt neo-LVOT area

May 28, 2026 249

TCTAP 2026

7-Year PARTNER 3 Trial: TAVR Demonstrates Long-Term Clinical Equivalence to Surgery in Low-Risk Pati...

At TCTAP 2026, David J. Cohen, MD (Cardiovascular Research Foundation, USA) presented the 7-year follow-up results of the PARTNER 3 trial. The analysis provided long-term insights into the comparative durability, safety, and efficacy of transcatheter aortic valve replacement (TAVR) versus surgical aortic valve replacement (SAVR) in low-surgical-risk patients with symptomatic severe aortic stenosis. Background The original PARTNER 3 trial demonstrated superior outcomes for TAVR over surgery at 1 year, but between-group differences attenuated through the 5-year follow-up. Because favorable surgical bioprosthetic valve durability has been reported for 10 or more years while early valve failure can occur as soon as 5 to 7 years post-procedure, a comprehensive 7-year dataset was considered essential. This long-term evaluation was particularly relevant given that TAVR is increasingly performed in younger patients with longer life expectancy, where understanding long-term transcatheter and surgical valve durability is critical for patient-centered decision making. Study Design and Long-Term Methodology PARTNER 3 randomized 1,000 patients with symptomatic severe aortic stenosis and low surgical risk (STS score < 4%) in a 1:1 fashion to TAVR with the SAPIEN 3 transcatheter heart valve or to surgery with a standard surgical bioprosthesis. Clinical follow-up was scheduled at 30 days, 6 months, and annually through 10 years, with protocol-driven echocardiographic assessment at 30 days, 6 months, annually from 1 to 5 years, and at 7 and 10 years. One-year endpoints and definitions were supplemented with outcomes more relevant to long-term follow-up, especially valve durability and late clinical events. To address the inherent challenges of long-term follow-up — including data missingness, withdrawal, loss to follow-up, and the competing risk of death — investigators performed vital status sweeps (VSS) at participating sites using patient and family phone calls, medical records, and publicly-available data. As a result, 89.6% of randomized patients were available for primary endpoint analysis at 7 years. Primary Endpoints Primary Endpoint 1, a non-hierarchical composite of all-cause death, stroke, or valve/procedure/heart failure-related rehospitalization, occurred in 34.6% of TAVR patients versus 37.2% of surgery patients, with a 7-year hazard ratio (HR) of 0.87 (95% CI, 0.70–1.08; P = 0.21). Primary Endpoint 2 evaluated a hierarchical composite of all-cause death (with VSS), disabling stroke, non-disabling stroke, and rehospitalization days, assessed using the win ratio method across 225,184 patient pairs. TAVR accumulated 28.8% total wins versus 27.6% for surgery, with 43.6% ties, yielding a win ratio of 1.04 (95% CI, 0.84–1.30; P = 0.70). Adjudication of Causes of Death Investigators categorized all deaths through 7 years into cardiovascular and non-cardiovascular causes. Cardiovascular deaths occurred in 46 TAVR and 31 surgery patients. Within this category, cardiac causes accounted for 18 TAVR and 12 surgery deaths, with congestive heart failure representing 7 and 6 deaths respectively. Non-coronary vascular conditions accounted for 14 TAVR and 6 surgery deaths, including 6 versus 4 stroke deaths and 6 versus 0 deaths from traumatic head injury due to a fall. Cause of death was classified as unknown in 14 TAVR and 13 surgery patients within cardiovascular adjudication. Non-cardiovascular deaths totaled 45 in the TAVR arm and 29 in the surgery arm. Cancer was the leading non-cardiovascular cause, accounting for 18 TAVR and 11 surgery deaths, followed by respiratory failure (12 versus 10; attributable to COVID-19, chronic respiratory disease, or pneumonia) and sepsis (8 versus 3). For a small subset of patients identified through vital status sweeps, the specific cause of death could not be determined (3 TAVR versus 13 surgery). Valve Durability and Hemodynamics All-cause bioprosthetic valve failure (BVF), adjudicated using VARC-3 definitions and analyzed with the Fine and Gray method to account for death as a competing risk, remained low and statistically similar between arms. At 7 years, BVF occurred in 6.9% of TAVR patients and 7.5% of surgery patients (HR 0.90, 95% CI 0.55–1.49; P = 0.69). Aortic valve reintervention occurred in 6.7% of TAVR and 6.0% of surgery patients (HR 1.11, 95% CI 0.63–1.94; P = 0.72). Valve hemodynamics remained excellent in both arms over 7 years. Mean aortic gradient at 7 years was 13.1 mmHg for TAVR and 12.1 mmHg for surgery — clinically low in both groups, although the modest between-group difference reached statistical significance (P = 0.02). Aortic valve area at 7 years was 1.93 cm² for TAVR and 1.84 cm² for surgery (P = 0.42). Conclusions In his concluding remarks, he emphasized that, among low-surgical-risk patients with symptomatic severe aortic stenosis followed for 7 years, both TAVR and surgery were associated with similar rates of clinical events, with no significant differences in either primary endpoint. The attenuation of primary endpoint differences originally observed at 5 years continued through 7 years. Marked 1-year improvements in hemodynamics and patient-reported outcomes were maintained and similar for both therapies, and valve function and durability were excellent and similar in both groups. These findings continue to support TAVR as an effective therapy for low-risk surgical candidates with severe aortic stenosis, with 7-year clinical, health status, and echocardiographic outcomes similar to surgical AVR. TCTAP Workshops Comprehensive TAVR Management Thursday, April 30, 8:30 AM ~ 10:00 AM Valve & Endovascular Theater, Level 1 Watch Session Video

May 28, 2026 236

TCTAP 2026

Imaging for Coronary Calcium

Coronary artery calcium was presented as a major determinant of procedural complexity and long-term outcomes in contemporary percutaneous coronary intervention. Speaking on May 2 during the Hot Topics session at TCTAP 2026, Gary S. Mintz, MD (Cardiovascular Research Foundation, USA), reviewed the clinical impact of calcified coronary lesions and emphasized the importance of imaging for calcium detection, lesion preparation, and stent optimization. The presentation first distinguished eruptive calcified nodules from non-eruptive nodular calcium. Eruptive calcified nodules were characterized by fibrous cap disruption, protrusion into the lumen, and overlying platelet or fibrin thrombus. These lesions were described as an important mechanism of acute coronary syndrome, particularly in older patients, patients with NSTEMI, and patients on dialysis. In contrast, non-eruptive nodular calcium occurred within the plaque, did not disrupt the fibrous cap, and was more commonly associated with stable coronary disease. A major focus of the presentation was the limitation of angiography in evaluating calcified coronary lesions. Although angiography could detect obvious calcification, it did not reliably quantify the extent, arc, depth, or circumferential distribution of calcium. Historical IVUS data showed that angiography had only moderate sensitivity for detecting extensive lesion calcium. In particular, only a minority of lesions with angiographically severe calcium had an IVUS calcium arc greater than 270 degrees, indicating that angiographic severity did not always reflect the true calcium burden. IVUS and OCT were presented as complementary imaging modalities for calcium assessment. IVUS detected calcium more frequently than angiography and provided important information on calcium arc, distribution, vessel size, and remodeling. OCT offered higher-resolution assessment of superficial calcium, calcium thickness, calcium length, and calcium fracture after lesion preparation. However, OCT could miss some calcium when signal attenuation obscured deeper structures, suggesting that modality selection should depend on the clinical question and lesion characteristics. Several imaging-based calcium scoring systems were reviewed. OCT-based calcium scoring incorporated calcium angle, thickness, and length to predict stent expansion. Lesions with a higher OCT calcium score were more likely to have suboptimal stent expansion, and calcium modification was recommended when the score was high. IVUS-based calcium scoring also predicted stent underexpansion, especially in lesions with calcium greater than 270 degrees. Important IVUS features included long calcium length, circumferential calcium, presence of a calcified nodule, and smaller vessel size. The presentation emphasized that severely calcified lesions should not be stented until adequate calcium modification had been confirmed. Detection of calcium fracture by intravascular imaging was highlighted as an important marker of successful lesion preparation. This approach was intended to reduce the risk of stent underexpansion, which remained one of the major mechanisms of poor outcomes after PCI in calcified lesions. Clinical evidence supported the value of intravascular imaging guidance in heavily calcified coronary lesions. A random-effects meta-analysis showed that IVUS- or OCT-guided PCI was associated with fewer major adverse cardiovascular events than angiography-guided PCI. In the ILUMIEN IV subgroup of patients with moderate or severe angiographic calcium, OCT-guided PCI reduced target vessel failure compared with angiography-guided PCI. The CALIPSO trial also showed that OCT guidance improved minimum stent area compared with angiographic guidance in patients with moderate to severe calcified lesions. The ECLIPSE trial, which compared orbital atherectomy with balloon angioplasty in severely calcified lesions, did not show a significant reduction in 1-year target vessel failure with orbital atherectomy. The primary imaging endpoint also did not show a statistically significant improvement in stent area at the site of maximum calcium. However, a subsequent analysis demonstrated that intravascular imaging guidance was associated with lower target vessel failure than angiography guidance alone. These findings suggested that imaging-guided confirmation of lesion preparation and stent expansion may be more important than the routine use of any single calcium modification device. The presentation also reviewed recent data comparing different calcium modification strategies. In moderately to severely calcified lesions, intravascular lithotripsy showed comparable imaging outcomes to cutting balloon or high-pressure balloon-based strategies. These data suggested that multiple calcium modification tools could be effective when selected appropriately, but their success depended on adequate imaging-based assessment and confirmation of stent expansion. The role of coronary computed tomography angiography was also introduced as an emerging approach for pre-procedural calcium assessment. CTA could provide three-dimensional information on calcium distribution, morphology, density, and compactness. This allowed evaluation of calcium beyond simple arc, thickness, and length, and could help operators understand the overall calcium burden before entering the catheterization laboratory. In conclusion, the presentation showed that coronary calcium was a complex and heterogeneous disease substrate that required careful imaging-based evaluation. Angiography alone was insufficient for precise calcium characterization. IVUS, OCT, and CTA each provided distinct but complementary information for lesion assessment, calcium modification, and PCI optimization. The key message was that operators should use imaging to identify severe calcium, guide lesion preparation, confirm calcium fracture, and ensure adequate stent expansion before completing PCI in calcified coronary lesions. Hot Topics Breaking the Complex Calcified Lesions: NC Balloon, Cutting Balloon, Rotational and Orbital Atherectomy, and IVL Saturday, May 2, 9:55 AM ~ 11:20 AM Coronary Theater, Level 1 Watch Session Video

May 21, 2026 260

TCTAP 2026

DCB for De Novo Lesions: Lesion Preparation Is the New Discipline

At TCTAP 2026, Peter O’Kane, MD (University Hospitals Dorset NHS Foundation Trus, United Kingdom) reviewed the contemporary evidence for drug-coated balloon (DCB) treatment of de novo coronary lesions, focusing on the two largest randomized trials in the field—SELUTION DeNovo and REC-CAGEFREE I—together with the earlier DEBUT trial. His central message was that DCB technology was not a uniform “class effect,” and that the discipline of lesion preparation, rather than the device itself, increasingly determined outcomes in a leave-nothing-behind strategy. The rationale for a metal-free approach, he explained, lay in the persistent 2–4% annual attrition of late adverse events seen with drug-eluting stents (DES). He cautioned that paclitaxel and sirolimus DCBs differed fundamentally in their drugs and excipients, so trial data had to be interpreted device by device. DEBUT and REC-CAGEFREE I The DEBUT trial (Rissanen et al., Lancet 2019) provided the first randomized signal: in 208 high bleeding risk patients, major adverse cardiac events at 9 months occurred in 1% of the paclitaxel DCB group versus 14% of the bare-metal stent group. REC-CAGEFREE I, a device trial of 2,046 patients randomized after lesion preparation to a paclitaxel DCB or a sirolimus-eluting stent, was more cautionary. The DCB had not met non-inferiority at 1 year, and the 3-year follow-up confirmed a worse device-oriented composite endpoint with the DCB (8.2% vs 5.0%; HR 1.68; 95% CI 1.21–2.34), driven mainly by greater target-lesion revascularization. He noted that the largest differences favored DES in larger vessels, reinforcing that a stent remained hard to beat in very simple lesions. SELUTION DeNovo The centerpiece was SELUTION DeNovo, the largest randomized coronary DCB trial to date. Unlike REC-CAGEFREE I, it was a strategy trial: 3,323 patients across 62 sites were randomized before lesion preparation to a sirolimus-eluting balloon strategy with provisional stenting, or to systematic DES, with STEMI and chronic total occlusions excluded. At 1 year, target vessel failure occurred in 5.3% of the DCB arm versus 4.4% of the DES arm, meeting the prespecified non-inferiority margin in the intention-to-treat analysis, with the difference driven almost entirely by clinically indicated revascularization and no excess in lesion thrombosis. Roughly 80% of DCB-arm patients were treated without a permanent implant, while about 20% of DES-arm patients ultimately received a DCB or alternative management—underscoring that neither strategy should be applied dogmatically. He noted that the per-protocol analysis did not confirm non-inferiority, but explained that the excluded patients had more complex lesions and high event rates—many of them protocol violations in which a DCB had been used in a DES-assigned patient—so the result reflected lesion difficulty rather than device failure. Exploratory subgroups suggested calcified lesions and high bleeding risk patients tended to favor the DCB strategy, while DES appeared to perform better in women. Comparing the Two Pivotal De Novo DCB Trials Feature SELUTION DeNovo REC-CAGEFREE I Trial design Strategy trial; randomized before lesion preparation Device trial; randomized after lesion preparation DCB type / comparator Sirolimus-eluting balloon + provisional stenting vs systematic DES Paclitaxel DCB with rescue stenting vs sirolimus-eluting stent Sample size 3,323 patients, 62 sites 2,046 patients, 43 sites Primary endpoint result TVF at 1 year 5.3% vs 4.4%; non-inferior (ITT) DoCE at 3 years 8.2% vs 5.0%; HR 1.68 (1.21–2.34); not non-inferior Key takeaway A DCB-first strategy with optimal lesion preparation is a viable alternative; ~80% avoided a permanent implant In simple lesions, a stent remains hard to beat; the antirestenotic efficacy decrement was clinically meaningful Lesion Preparation as the Common Denominator Drawing on his experience as the UK national principal investigator for SELUTION DeNovo, he stressed that the recurring lesson was the importance of meticulous lesion preparation. He illustrated this with a trial case in which a severe lesion was treated with cutting and non-compliant balloons to achieve a type B dissection with good flow and no significant recoil, allowing completion with a single sirolimus DCB and no stent; CT angiography at 19 months confirmed a durable result in an asymptomatic patient. He added that SELUTION DeNovo demonstrated procedural safety in a large cohort treated by many operators still on their DCB learning curve, strengthening the external validity of the result. Conclusion He concluded that the de novo DCB evidence base was nuanced rather than uniformly positive. REC-CAGEFREE I was a reminder that in simple lesions a stent remained difficult to outperform, while SELUTION DeNovo showed that a sirolimus DCB strategy with provisional stenting could be non-inferior to systematic DES across a broad population. The unifying principle was that DCB outcomes depended less on the device label and more on the discipline of lesion preparation and patient selection. He closed by noting that the obligation remained to prove the leave-nothing-behind concept with rigorous science and data. Hot Topics New DCB Strategy in Modern PCI Saturday, May 2, 8:30 AM ~ 9:55 AM Coronary Theater, Level 1 Watch Session Video

May 21, 2026 259

TCTAP 2026

‘IVUS or Angiography-Guidance for Complex Bifurcation PCI’

Complex coronary bifurcation lesions remain among the most technically demanding subsets in contemporary PCI, particularly when a two-stent strategy is required. During TCTAP 2026, Shao-Liang Chen, MD (Nanjing First Hospital of Nanjing Medical University, China) presented the DKCRUSH VIII trial, demonstrating that IVUS-guided DK crush PCI significantly reduced 1-year target vessel failure compared with angiography-guided PCI in patients with true complex bifurcation lesions. The randomized study enrolled 556 patients across 24 Chinese centers who had complex bifurcation anatomy defined by a side-branch lesion length ≥10 mm, significant side-branch stenosis, and additional complexity features. Patients were randomized to IVUS-guided or angiography-guided DK crush PCI. At 1 year, the primary endpoint of target vessel failure occurred in 6.1% of the IVUS-guided group versus 14.7% of the angiography-guided group (HR 0.40, 95% CI 0.23–0.71; p=0.0016). The reduction was primarily driven by lower rates of target vessel myocardial infarction and clinically driven target vessel revascularization. Importantly, the study also highlighted how frequently procedural optimization issues remained undetected without intravascular imaging. IVUS assessment identified incomplete crush, distal wiring, or inadequate final optimization in a substantial proportion of cases throughout the DK crush procedure. Even after final POT, suboptimal procedural findings were observed in 61% of patients undergoing IVUS assessment. One of the most striking findings was that clinical benefit appeared closely linked to achievement of predefined IVUS optimization criteria rather than IVUS use alone. Patients who achieved “optimal PCI” based on IVUS-defined criteria had a markedly lower event rate compared with both angiography-guided PCI and IVUS-guided but suboptimally optimized procedures. He emphasized that complex bifurcation PCI remains highly dependent on precise procedural execution. The findings suggest that IVUS guidance may help operators systematically identify and correct procedural shortcomings that are difficult to recognize with angiography alone. The DKCRUSH VIII results further reinforce the growing role of intravascular imaging in complex PCI and support a strategy focused not merely on imaging use, but on achieving imaging-guided optimization targets. Hot Topics Bifurcation PCI in 2026: Evolving Strategies and Key Controversies Friday, May 1, 10:50 AM ~ 12:20 PM Coronary Theater, Level 1 Watch Session Video

May 21, 2026 225

TCTAP 2026

AI for Coronary Imaging: Transformative Updates for 2026

With intravascular imaging (IVI)–guided PCI elevated to a Class IA recommendation, the next bottleneck became how the acquired data were analyzed. Speaking on April 30 during the TCTAP Workshops session “Integrating Imaging and Physiology for Optimal PCI” at TCTAP 2026, Soo-Jin Kang, MD, PhD (Asan Medical Center, Korea), emphasized that the conventional, single-frame–based reading approach was no longer sufficient — and that artificial intelligence (AI) analysis of the entire pullback better reflected long-term prognosis than frame-by-frame interpretation of the culprit lesion alone. Why was frame-by-frame analysis insufficient? Recent reviews highlighted recurring limitations of conventional AI-IVUS work, including reliance on single-frame–derived parameters, the lack of whole-vessel plaque characterization, the absence of hemodynamic context, underpowered samples, and the constraints of traditional statistics (Cho S et al., Int J Cardiol 2024;417:132543). These limitations explained why such analyses repeatedly underperformed in predicting hard endpoints, and they framed the rationale for whole-vessel AI analysis. The PECTUS-AI study (Pick et al., Eur Heart J 2025;46:5032–5041) provided the clearest evidence for this shift. AI analysis of the complete OCT pullback predicted 2-year MACE better than core-lab analysis confined to the target lesion only, even though the agreement between AI-derived and core-lab–defined TCFA was only fair to moderate. In other words, the prognostic signal lived in the whole vessel — including non-culprit segments — and was missed when reading was restricted to a single lesion or a few selected frames. Several ongoing Korean trials operationalized this whole-vessel concept. The INNOVATE-PCI registry (NCT05807841; 3,000 PCI patients, 16 centers) prospectively validated whole-pullback AI IVUS analysis against 2-year TVF; an interim ML model trained on 902 matched pullbacks predicted post-PCI underexpansion (MSA

May 21, 2026 257

TCTAP 2026

Stent Optimization in the Era of Class IA Imaging Guidance

With the 2024 ESC and 2025 AHA/ACC guidelines elevating intravascular imaging (IVI)–guided PCI to a Class IA recommendation for complex lesions, the practical question shifted from whether to image to which optimization target should actually be pursued at the bedside. Although the 2018 expert consensus listed multiple parameters — minimum stent area (MSA), stent expansion, malapposition, tissue prolapse, edge dissection, and reference-vessel disease — operators were left with too many criteria to remember, and definitions of optimal MSA varied across landmark trials, ranging from >4.5 to >5.0 mm² absolute, or 80–100% of reference lumen area. Speaking on April 30 during the TCTAP Workshops session “Integrating Imaging and Physiology for Optimal PCI” at TCTAP 2026, Myeong-Ki Hong, MD, PhD (Severance Hospital, Korea), emphasized that not all parameters carried equal predictive weight. Among them, post-PCI MSA was repeatedly identified as the most consistent and strongest predictor of both restenosis and stent thrombosis (Maehara, JACC Img 2017), establishing MSA as the essential core, while the remaining factors functioned as accessory contributors. Two pooled analyses pinpointed the most useful single MSA cut-off. The IVUS-XPL + ULTIMATE long-lesion pool (Circ Cardiovasc Interv 2021) showed that MSA >5.5 mm² conferred the strongest reduction in 3-year cardiac death, MI, or stent thrombosis (HR 0.21; 95% CI 0.06–0.75; p=0.008), outperforming MSA >5.0 mm² (HR 0.24) and MSA/distal reference >90% (HR 0.32). A subsequent pooled analysis of IVUS-XPL, ULTIMATE, and IVUS-ACS (JACC Intv 2025;18:2197–2205) confirmed that MSA >5.5 mm² remained the most consistent threshold for 1-year TVF across all-comers, long lesions, and acute coronary syndromes. Even when translated to angiography, the corresponding post-PCI MLD of ~2.92 mm (≈6–7 mm² circular area) aligned geometrically with the IVUS-derived 5.5 mm² target — a value that operators could intuitively estimate in the cath lab. The take-home message was therefore simple and easy to apply: in the new era of Class IA imaging guidance, MSA by IVUS >5.5 mm² should be remembered as the single, easiest, and most practical optimization target, while malapposition, tissue protrusion, edge dissection, and reference-vessel disease should be addressed only as accessory factors (Figure 1). Figure 1. MSA by IVUS >5.5 mm² — the essential, easy-to-remember core of stent optimization, with other factors as accessories. TCTAP Workshops Integrating Imaging and Physiology for Optimal PCI Thursday, April 30, 4:30 PM ~ 5:55 PM Valve & Endovascular Theater, Level 1 Watch Session Video

May 21, 2026 333

TCTAP 2026

Left Main Revascularization Hinges on Individualized Choices Beyond Trial Headlines

At TCTAP 2026, Sripal Bangalore, MD, MHA, professor of medicine at NYU Grossman School of Medicine and director of invasive and interventional cardiology at Bellevue Hospital Center, reviewed contemporary evidence comparing percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) for left main and multivessel coronary artery disease, framing the debate as a decision that had moved beyond a simple “PCI versus surgery” binary. He opened with a 72-year-old woman with Canadian Cardiovascular Society (CCS) class III angina, a positive stress echocardiogram, normal ejection fraction, severe calcification of the left main, ostial LAD, and LCX, and severe Medina 1,1,1 left main bifurcation disease, underscoring that both strategies offered meaningful but different tradeoffs. No Overall Mortality Difference, but Important Subgroup Signals Drawing on a meta-analysis he co-authored (Kuno, Bangalore et al., American Heart Journal 2020) of four randomized trials—EXCEL, NOBLE, the SYNTAX left main subgroup, and PRECOMBAT (n=4,394, follow-up ≥5 years)—together with the patient-level meta-analysis by Sabatine et al. (Lancet 2021;398:2247-57), Bangalore concluded that there was no overall mortality difference between PCI and CABG in left main disease. The recently reported NOBLE 10-year final results (Holck et al., Lancet 2026;407:1374-82) reinforced this finding, with all-cause mortality of 23% in the PCI arm versus 25% in the CABG arm (HR 0.93; 95% CI 0.74–1.18; p=0.56) and no significant interaction with SYNTAX score. He highlighted two clinically important subgroup signals. First, in the NOBLE acute coronary syndrome (ACS) cohort, PCI was associated with significantly lower long-term mortality than CABG (HR 0.57; 95% CI 0.32–0.99; p=0.047), suggesting that the physiology and urgency of ACS may have favored a less invasive upfront strategy in selected patients. Second, in pooled meta-analytic data, there appeared to be a possible advantage of CABG for cardiovascular death—not all-cause mortality—only at very high SYNTAX scores, indicating that anatomic complexity remained relevant for that specific endpoint at the most complex end of the spectrum. Tradeoffs Beyond Survival Bangalore explained that, across pooled trial data, CABG generally reduced spontaneous myocardial infarction and repeat revascularization, while PCI was associated with fewer peri-procedural complications, lower early stroke risk, and faster recovery. In the EXCEL quality-of-life analyses (Baron et al., JACC 2017;70:3113-22), PCI was associated with earlier improvement in physical function (SF-12 Physical Summary), dyspnea (Rose Dyspnea Scale), depression (PHQ-8), and angina frequency (Seattle Angina Questionnaire), with most differences narrowing or resolving by 12 to 36 months. His central message was that “patient preference matters,” particularly when weighing short-term risks of death and stroke with CABG against long-term risks of repeat revascularization after PCI. Table 1. Clinical tradeoffs in PCI versus CABG decision-making Domain PCI CABG Early recovery Generally faster Longer recovery Early procedural burden Lower peri-procedural complications in selected patients Higher short-term surgical risk Repeat revascularization Higher risk Lower risk Spontaneous MI Higher than CABG in pooled datasets Lower risk Stroke / peri-procedural events Lower early burden Higher peri-procedural burden Mortality signal in subgroups Possible benefit in ACS cohort (NOBLE 10-year) Possible benefit for CV death at very high SYNTAX scores Best suited for Equivalent complete revascularization achievable, lower anatomic complexity, high surgical risk, ACS in selected patients, patient preference Complex anatomy, very high SYNTAX score, durable complete revascularization Guidelines and Patient Selection Bangalore placed his conclusions in the context of the 2021 ACC/AHA/SCAI revascularization guideline, of which he was a co-author (Lawton, Tamis-Holland, Bangalore, et al., JACC 2021). The guideline recommended CABG to improve survival in patients with significant left main stenosis (Class 1), while stating that PCI was reasonable (Class 2a) in selected stable patients for whom PCI could provide equivalent revascularization to that possible with CABG. He also cautioned that the mean age of patients enrolled in the four landmark trials had ranged from 62 to 66 years (PRECOMBAT 62; SYNTAX 65; EXCEL and NOBLE 66)—considerably younger than many patients encountered in contemporary practice. Direct extrapolation of these results to substantially older patients, including the 72-year-old in his opening case, therefore required caution. Conclusion Bangalore concluded that revascularization choice should be individualized by a Heart Team, weighing the ability to achieve complete revascularization, short- and long-term event risks, clinical presentation (including ACS status), anatomic complexity at the highest SYNTAX tier, frailty, age, and informed patient goals. TCTAP Workshops Left Main & Multi-Vessel Disease: Modern Evidence and Real-World Strategy Thursday, April 30, 2:50 PM ~ 4:25 PM Main Arena, Level 1 Watch Session Video

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TCTAP 2026

Antithrombotic Therapy After TAVR: Balancing Bleeding and Thrombosis

At TCTAP 2026, Davide Capodanno, MD, PhD (University of Catania, Italy), delivered a comprehensive lecture on antithrombotic therapy after transcatheter aortic valve replacement (TAVR), focusing on how recent evidence has reshaped clinical practice and where uncertainties still remain. TAVR has rapidly expanded across all surgical risk categories, including younger and lower-risk patients. As procedural outcomes have improved, attention has increasingly shifted toward optimizing post-procedural management. Among these, antithrombotic therapy remains one of the most challenging aspects, requiring a careful balance between thrombotic risk and bleeding complications. He emphasized that contemporary management is now largely guided by the 2025 ESC/EACTS valvular heart disease guidelines. These guidelines reflect a major shift away from historically intensive antithrombotic strategies toward a simplified approach. In patients without an indication for oral anticoagulation (OAC), low-dose aspirin monotherapy was recommended as the standard treatment. This recommendation was supported by randomized trials such as POPULAR-TAVI, which demonstrated a significant reduction in bleeding without an increase in thrombotic events compared with dual antiplatelet therapy (DAPT). Accordingly, DAPT was no longer recommended in this population unless there was a clear clinical indication. The role of oral anticoagulation in patients without baseline indications was also critically reassessed. Trials such as GALILEO and ATLANTIS failed to show clinical benefit and, in some cases, suggested harm with routine anticoagulation. Based on these findings, the guidelines advised against routine use of OAC in patients undergoing TAVR without another indication. Despite these advances, several important areas of uncertainty remained. One of the most debated issues was subclinical leaflet thrombosis, typically detected as hypoattenuated leaflet thickening (HALT) on computed tomography. While HALT has been reported in a substantial proportion of patients after TAVR, its clinical significance remains unclear. Although anticoagulation has been shown to reduce imaging-detected thrombosis, this has not consistently translated into improved clinical outcomes such as stroke or mortality. He highlighted that this gap between imaging findings and clinical outcomes represents a key unresolved issue in the field. As a result, routine anticoagulation based solely on imaging findings has not been adopted in current practice. To address these uncertainties, several ongoing trials are actively investigating more refined and individualized strategies. These include CT-guided approaches, in which anticoagulation is initiated only when subclinical valve thrombosis is detected, as well as trials exploring further reduction or even discontinuation of antithrombotic therapy after TAVR. Importantly, these studies are expected to determine whether treatment decisions can be guided by imaging findings rather than applied uniformly to all patients. This represents a potential paradigm shift toward precision medicine in post-TAVR management. In patients with a clear indication for anticoagulation, such as atrial fibrillation, the strategy differed. Evidence from trials including POPULAR-TAVI and ENVISAGE-TAVI suggested that oral anticoagulation alone was generally sufficient, and that combination therapy with antiplatelet agents should be avoided whenever possible due to the increased risk of bleeding. Overall, his lecture underscored a fundamental transition in the field. Antithrombotic therapy after TAVR has evolved from empiric and intensive regimens toward a simplified, guideline-driven approach, while key clinical questions continue to be addressed through ongoing trials (Figure 1). As TAVR continues to expand into broader patient populations, the results of these studies are expected to further refine treatment strategies and shape future guidelines. Figure 1. Antithrombotic Therapy After TAVR: Simplification Amid Unanswered Questions Hot Topics TAVR Practice in 2026: Insights for the Next Era Friday, May 1, 8:30 AM ~ 9:57 AM Valve & Endovascular Theater, Level 1 Watch Session Video

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