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TCTAP 2026

Rethinking Antithrombotic Therapy in AF with Stable CAD: Are We Finally Ready to Let Go of Antiplate...

At TCTAP 2026, Jung-Sun Kim, MD, PhD (Severance Hospital, Korea) addressed a fundamental question in current practice: whether antiplatelet therapy is still necessary in patients with atrial fibrillation (AF) and stable coronary artery disease (CAD). He noted that both the 2023 ESC and 2023 ACC/AHA guidelines recommend discontinuing antiplatelet therapy 6–12 months after percutaneous coronary intervention (PCI), with long-term management based on oral anticoagulant (OAC) monotherapy. The clinical focus, therefore, has shifted from choosing the optimal combination to determining whether any antiplatelet therapy is needed at all. To answer this question, he reviewed a series of randomized trials. The OAC-ALONE trial, although one of the earliest studies, was terminated early and failed to demonstrate non-inferiority, leaving uncertainty unresolved. The AFIRE trial provided the first major signal, showing that rivaroxaban monotherapy was superior to combination therapy for both efficacy and safety outcomes. However, its interpretation was limited by the exclusive Japanese population and use of lower-than-standard doses, raising concerns about generalizability. The EPIC-CAD trial addressed this limitation by evaluating standard-dose edoxaban in a broader population. Monotherapy significantly reduced net adverse clinical events, mainly driven by less bleeding, without increasing ischemic risk. This confirmed that direct OAC (DOAC) monotherapy can be both safe and effective at standard doses. However, the heterogeneous study population left uncertainty regarding patients with contemporary drug-eluting stents. The AQUATIC trial focused on patients with stents and high atherothrombotic risk. Even in this group, adding aspirin to OAC did not improve ischemic outcomes but increased bleeding risk, challenging the role of aspirin as the default antiplatelet agent. “Clopidogrel has often shown better outcomes than aspirin for long-term antiplatelet therapy, and further evidence specifically evaluating clopidogrel-based combination therapy was needed,” he said. The ADAPT AF-DES trial further evaluated patients with contemporary drug-eluting stents using clopidogrel as the sole antiplatelet agent. DOAC monotherapy was non-inferior—and even superior—for net adverse clinical events, primarily due to reduced bleeding. This suggested that even clopidogrel does not provide additional benefit when combined with anticoagulation in stable patients. Clinical outcomes of the ADAPT AF DES Trial Taken together, these trials deliver a consistent message: adding antiplatelet therapy does not meaningfully reduce ischemic events but increases bleeding risk. The safety of DOAC monotherapy has been reproducible across different populations and clinical settings. “Despite this, uncertainty remains in patients with high ischemic risk, such as those undergoing complex PCI or with polyvascular disease. The ongoing ADAPT AFFIRM trial is expected to provide further insight by comparing apixaban monotherapy with combination therapy in this population,” he said. In conclusion, he emphasized three key points. First, in patients with AF and stable CAD beyond 12 months after contemporary DES implantation, DOAC monotherapy should be considered the default strategy. Second, continued antiplatelet therapy generally increases bleeding without clear ischemic benefit. Finally, further evidence is needed in high-risk populations. Hot Topics Evolving Medical Therapy in Interventional Cardiology: Evidence to Innovation Friday, May 1, 2:55 PM ~ 4:20 PM Presentation Theater 2, Level 1 Check the Session

May 14, 2026 268

TCTAP 2026

Six Decades of Coronary Revascularization: CABG’s Enduring Edge

David Paul Taggart, MD, PhD (University of Oxford, United Kingdom), recipient of the 16th TCTAP Master of the Masters Award, delivered a sweeping assessment of coronary revascularization spanning the field’s six-decade history-from Favaloro’s first bypass graft in 1967 to the latest generation of drug-eluting stents. His verdict: despite relentless advances in percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG) retains a durable survival advantage in most patients with multivessel or left main disease, and wide geographic variation in PCI-to-CABG ratios reflects physician preference more than evidence. A Tale of Two Pioneers In 1967, René Favaloro-the ‘father of CABG’-reported the systematic use of reversed saphenous vein grafting to treat multivessel coronary artery disease. Almost a decade later, Andreas Grüntzig described the opening of stenosed coronary arteries with a balloon, laying the foundation for interventional cardiology. Despite this parallel evolution, he was unequivocal: the long-predicted demise of CABG has not occurred. The fundamental CABG operation has changed little in 60 years, with saphenous vein increasingly replaced by the internal mammary artery and other arterial conduits. In contrast, PCI has evolved through numerous stent generations. Yet even contemporary PCI, he stressed, does not match CABG outcomes in many patients with complex disease. The long-predicted demise of CABG has not occurred. Despite never-ending improvements in stent technology, PCI does not match the results of CABG in many patients with multivessel or left main disease. David Paul Taggart, MD, PhD Multivessel Disease: SYNTAX and FAME III Early trials comparing PCI and CABG were confounded by enrolling patients with low-complexity disease that poorly reflected real-world practice. The SYNTAX trial addressed this by adopting a relative “all-comers” design-though 40% of screened patients had disease so severe they were referred directly for CABG rather than randomized. At five years, CABG demonstrated a significant overall survival advantage of approximately 5% over PCI, accompanied by marked reductions in myocardial infarction (MI) and the need for repeat revascularization. Crucially, when patients were stratified by SYNTAX score, the survival benefit of CABG widened with increasing disease complexity-roughly 7% in the intermediate-score group and 9% in the highest-risk tier. More recently, the FAME III trial, using fractional flow reserve (FFR)-guided PCI with contemporary drug-eluting stents, still failed to match CABG outcomes. These advantages are further amplified in patients with diabetes and impaired ventricular function, he noted. Trial / Comparison Key Finding CABG Advantage SYNTAX (MVD, 5-yr) All-cause mortality, MI, repeat revasc. ~5% overall survival benefit SYNTAX (High SYNTAX Score) Survival by disease severity +9% survival vs PCI FAME III (FFR-guided PCI) Contemporary DES vs CABG CABG still superior EXCEL (LMD, 5-yr) SYNTAX score ≤32 Clear survival benefit; ↓MI Table: Selected landmark trials comparing CABG and PCI. MVD = multivessel disease; LMD = left main disease; DES = drug-eluting stent; MI = myocardial infarction. Left Main Disease: The EXCEL Controversy The left main (LM) coronary artery debate has proven more contentious. The EXCEL trial-the most definitive study in selected LM disease with SYNTAX scores below 32-demonstrated a clear and accelerating survival benefit for CABG at five years, along with a marked reduction in MI on conventional biochemical definitions. Yet the cardiology literature subsequently became flooded with meta-analyses combining EXCEL results with smaller, underpowered studies of less severe disease, effectively diluting the mortality signal until CABG’s benefit “disappeared” from pooled estimates. Today, there is broad consensus that LM disease with SYNTAX scores above 32 is an indication for CABG unless contraindicated. Lesser-severity LM disease remains debated. He acknowledged a notable exception: patients with true ostial or isolated mid-shaft LM stenosis may achieve excellent outcomes with PCI-possibly because competitive flow from bypass grafts reduces graft efficacy in anatomically favorable lesions. Why CABG Retains Its Edge: Three Fundamental Differences ending improvements in stent technology, and whose benefits grow ever more durable with longer follow-up-extending beyond 10 years. He emphasized the most important: 1. Bypass grafts protect the whole proximal coronary circulation-independent of the complexity of the proximal culprit lesion and from the progression of, or development of, further proximal disease. This is witnessed by the sustained reduction in subsequent myocardial infarction with CABG versus PCI in longer-term studies. 2. The internal thoracic artery exerts beneficial vasoactive effects that may actively promote long-term vessel health-a biological property no stent platform can replicate. 3. CABG more reliably achieves complete revascularization, a factor consistently associated with improved long-term outcomes across disease subsets. The PCI:CABG Ratio Gap—Evidence vs. Practice Perhaps the most provocative element of his lecture was his challenge to the global mismatch between evidence and practice. Despite more than two decades of trial data demonstrating CABG’s superiority for most patients with multivessel and left main disease, the ratio of PCI to CABG varies enormously among countries and even within regions of the same country—variations that cannot be explained by differences in patient populations alone. Both PCI and CABG are complementary therapies when used in appropriate patients, he acknowledged. But he was blunt about the evidence gap: best evidence has demonstrated the superiority of CABG for most patients with multivessel and left main disease for over two decades. Given the same evidence base, the enormous discrepancies in PCI-to-CABG ratios across countries—and within regions of the same country—have only one plausible explanation: “clinical practice is largely dictated by physician preference rather than evidence basis, and that may be detrimental to the best interests of the patient.” The Heart Team Imperative His prescription was clear: the only effective solution is properly constituted multidisciplinary heart teams empowered to make evidence-based recommendations—so that patients can then make a truly informed decision. Both procedures, he stressed, are complementary when deployed in the right patient. The gulf between evidence and practice, he implied, is a failure not of science but of how clinical decisions are made. The lecture offered a sweeping reminder that six decades of evidence consistently point in the same direction—and that the greatest remaining challenge may not be technological, but organizational. Taggart reports no relevant conflicts of interest. TCTAP Award 2026 16th TCTAP Master of the Masters Award Thursday, April 30, 11:25 AM ~ 11:55 AM Main Arena, Level 1 Check the Session

May 1, 2026 284

TCTAP 2026

‘Practical Guideline for Bifurcation PCI: Don't Touch!’

At TCTAP 2026, during the “Bifurcation PCI in 2026: Evolving Strategies and Key Controversies” session, Seung-Jung Park, MD, PhD (Asan Medical Center, Korea) will deliver a forward-looking lecture that will redefine contemporary approaches to non-left main (non-LM) bifurcation PCI in the era following the ISCHEMIA trial. His central message will be both provocative and practice-changing: “Don’t touch small side branches.” Drawing on robust evidence from randomized trials and meta-analyses, he will emphasize that percutaneous coronary intervention (PCI) will not confer a survival benefit over optimal medical therapy (OMT) in patients with stable ischemic heart disease-even among those with multivessel disease or moderate to severe ischemia. This paradigm shift will fundamentally reshape the goals of revascularization, moving from anatomical completeness toward physiologic relevance and symptom-driven intervention. A key concept that will be highlighted is the true myocardial significance of side branches. Based on fractional myocardial mass (FMM) data, the majority of side branches in non-LM bifurcation lesions will supply less than 10% of the total myocardium. In practical terms, this will mean that most side branches-particularly those with a reference vessel diameter 2.5 mm), however, a more nuanced approach will be required. In cases of true bifurcation lesions-such as Medina 1,1,1 or 0,1,1-he will advocate for upfront two-stent strategies, particularly when the side branch supplies a substantial myocardial territory or when symptoms are present. Nonetheless, even in these scenarios, treatment decisions will be guided by clinical and physiologic relevance rather than angiographic appearance alone. He will conclude by summarizing his practical clinical rules for non-LM bifurcation PCI: 1. Do not treat small side branches (

May 1, 2026 315

TCTAP 2026

M-TEER in Secondary Mitral Regurgitation: Evidence That Shapes Practice

At TCTAP 2026, Gregg W. Stone, MD (Mount Sinai, USA) will deliver a comprehensive lecture on mitral transcatheter edge-to-edge repair (M-TEER) in secondary mitral regurgitation (MR), synthesizing the pivotal randomized controlled trial data that has come to define contemporary clinical practice in this challenging patient population. Secondary MR, also known as functional MR (FMR), arises not from intrinsic leaflet pathology but from left ventricular remodeling and dysfunction, making its management fundamentally different from primary MR. He will begin by framing the central debate that has dominated the field: the divergent outcomes of three landmark randomized trials-COAPT, MITRA-FR, and RESHAPE-HF2-each of which enrolled patients with heart failure and FMR treated with guideline-directed medical therapy (GDMT), with or without M-TEER using the MitraClip device. Key Inclusion Criteria Across Three Major M-TEER Randomized Trials Criteria COAPT (n=614) MITRA-FR (n=304) RESHAPE-HF2 (n=505) NYHA class II-IVa II-IV II-IVa LVEF 20-50% 15-40% 20-50% LVESD 70 mmHg No exclusions No exclusions RV dysfunction Exclude moderate or severe No exclusions Exclude severe TR Exclude severe w/planned intervention No exclusions Exclude severe The COAPT trial (n=614) demonstrated a striking benefit of MitraClip added to maximally tolerated GDMT. Hospitalizations for heart failure were reduced by 47% (67.9%/yr vs. 35.8%/yr; HR 0.53 [95% CI 0.40-0.70], P=0.000006), with a number needed to treat (NNT) of just 3.1 at 24 months. All-cause mortality was similarly reduced, with 29.1% in the MitraClip group versus 46.1% in the GDMT-alone group at 24 months (HR 0.62 [95% CI 0.46-0.82], P=0.0007; NNT 5.9). Patient-reported quality of life, as assessed by the Kansas City Cardiomyopathy Questionnaire Overall Summary Score (KCCQ-OSS), showed sustained and clinically meaningful improvements of more than 12 points above the minimum clinically important difference throughout the two-year follow-up period in the device arm. In contrast, MITRA-FR (n=304) showed no benefit of MitraClip over medical therapy alone at 24 months, with nearly identical rates of death or heart failure hospitalization in both groups (63.8% vs. 67.1%; HR 1.01 [95% CI 0.77-1.34], P=0.92). He will emphasize that the divergence between COAPT and MITRA-FR was largely explained by patient selection differences. Critically, COAPT enrolled patients with "disproportionately severe" MR-defined by a high effective regurgitant orifice area (EROA) relative to left ventricular end-diastolic volume (LVEDV)-while MITRA-FR enrolled patients with relatively "proportionate" MR, where the degree of regurgitation was more commensurate with the extent of LV dilation. He will then turn to the RESHAPE-HF2 trial (n=505), which provided additional confirmatory evidence supporting M-TEER in appropriately selected patients. The trial met its co-primary endpoints, demonstrating a 36% relative risk reduction in the composite of cardiovascular death or heart failure hospitalization (rate ratio 0.64 [95% CI 0.48-0.85]; P=0.002), and a 41% reduction in heart failure hospitalizations alone (rate ratio 0.59 [95% CI 0.42-0.82]; P=0.002), with an NNT of 8.3 to prevent one death or HFH. Quality of life improvements on the KCCQ-OSS at one year were also significantly greater in the device group (mean difference 10.9 points; 95% CI 6.8-15.0; P

May 1, 2026 293

TCTAP 2026

Angiography-Derived Physiology for PCI: The ALL-RISE Trial

At the Late-Breaking Clinical Trials session during TCTAP 2026, William F. Fearon, MD (Stanford University School of Medicine, USA) will present the highly anticipated results of the ALL-RISE trial. Assessing coronary physiology with an intracoronary pressure wire improves clinical outcomes in patients undergoing cardiac catheterization and percutaneous coronary intervention (PCI). However, the clinical use of pressure wire-based physiology remains low. During his lecture, he will explain that the measurement of fractional flow reserve (FFR) derived from coronary angiographic images alone (FFRangio) correlates well with pressure wire-based FFR and may simplify procedures, but its effect on clinical outcomes has remained unknown. In this multicenter, international, non-inferiority trial, patients undergoing coronary angiography who were found to have at least one intermediate coronary stenosis were randomized to FFRangio or to wire-based physiologic assessment. The primary outcome was a composite of death, myocardial infarction, or unplanned clinically indicated coronary revascularization at one year, which was tested for non-inferiority with an absolute margin of 3.5%. Key secondary endpoints included procedural time, radiation exposure, and contrast media utilization. From 59 sites, 1,930 patients were randomized to either FFRangio (n=965) or to wire-based assessment (n=965). The composite endpoint of death, myocardial infarction, or revascularization occurred in 6.9% of those randomized to FFRangio and 7.1% of those randomized to wire-based assessment (difference, -0.2%; upper 97.5% CI, 2.1%), p=0.0008 for non-inferiority). Furthermore, the event rates for each component of the composite were similar between the two randomized groups. Figure 1. Kaplan-Meier Curve for the Primary Endpoint. The graph illustrates the cumulative incidence of the primary composite endpoint over 12 months since randomization. The red line represents the FFRangio group, while the blue line represents the Pressure Wire group. Beyond the primary clinical endpoints, the FFRangio-guided strategy reduced procedural time, radiation exposure, and contrast media utilization. These reductions will greatly benefit daily catheterization lab efficiency and safety. He will conclude that in patients with intermediate coronary disease requiring physiologic assessment in the cardiac catheterization laboratory, an FFRangio-guided strategy streamlined the procedure and was non-inferior with respect to clinical outcomes at one year compared with a pressure wire-guided strategy. These findings may support the broader integration of image-based physiological assessments as a viable alternative in routine PCI workflows. Clinical Science Late-Breaking Clinical Trials 2026 Friday, May 1, 8:30 AM ~ 9:55 AM Presentation Theater 1, Level 1 Check the Session

May 1, 2026 223

TCTAP 2026

PCI vs. CABG in Diabetic Multivessel Disease: A Turning Point in the Era of Contemporary Revasculari...

At TCTAP 2026, Duk-Woo Park, MD, PhD (Asan Medical Center, Korea), will present a timely lecture addressing one of the most enduring controversies in interventional cardiology: the optimal revascularization strategy for patients with diabetes mellitus and multivessel coronary artery disease. For decades, coronary artery bypass grafting (CABG) has been regarded as the standard of care in this high-risk population, supported by landmark randomized trials such as FREEDOM and BARI-2D. These studies demonstrated superior outcomes of CABG over percutaneous coronary intervention (PCI), particularly in reducing death and myocardial infarction. However, a critical limitation exists. These trials were conducted in an era that does not reflect contemporary clinical practice. First-generation drug-eluting stents, limited use of intravascular imaging, and absence of modern guideline-directed medical therapy-including sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists -raise concerns regarding the applicability of historical data to current patients. Over the past decade, PCI has undergone a profound transformation. Advances include next-generation drug-eluting stents, routine use of intravascular imaging (intravascular ultrasound (IVUS) and optical coherence tomography (OCT)), physiology-guided PCI using fractional flow reserve (FFR0 or instantaneous wave-free ratio (iFR), and integration of contemporary medical therapy. Modern PCI is no longer a purely device-based intervention, but rather a comprehensive, optimized strategy. In this context, the DEFINE-DM trial has been designed to address the critical evidence gap. This multicenter randomized trial will enroll approximately 1,500 patients with diabetes and three-vessel disease, comparing state-of-the-art PCI with contemporary CABG. The PCI arm will incorporate mandatory imaging and physiology guidance, while both groups will receive optimized medical therapy. The primary endpoint will be a composite of all-cause death, myocardial infarction, or stroke at 2 years, with the study powered to test non-inferiority of PCI. Importantly, DEFINE-DM represents more than a comparison of two revascularization techniques. It evaluates two fully optimized treatment strategies in the modern era. This distinction marks a paradigm shift in how revascularization trials should be interpreted. If PCI demonstrates comparable outcomes to CABG, it could significantly expand treatment options and influence future clinical guidelines. Conversely, if CABG remains superior, it will reinforce its role as the gold standard even in the contemporary era. Ultimately, the management of diabetic multivessel coronary artery disease stands at a critical crossroads. DEFINE-DM is expected to provide definitive evidence to guide the next generation of revascularization strategies and shape clinical decision-making worldwide. 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 Check the Session

April 30, 2026 246

TCTAP 2026

TAVR Valve Durability in 2026

At the upcoming TCTAP 2026 conference, Tullio Palmerini, MD (S. Orsola-Malpighi Polyclinic, Italy) will present an essential clinical update on structural longevity. His presentation, focusing on transcatheter heart valve durability, will address the evolving paradigm of lifetime management. As indications for transcatheter aortic valve replacement will increasingly expand toward younger and lower-risk patients with severe aortic valve stenosis, their longer life expectancy will make valve durability a critical determinant of clinical success. The potential need for future reinterventions will dictate that the cardiovascular community will meticulously evaluate how these bioprosthetic valves will perform over the coming decades. During the session, he will elucidate that transcatheter heart valve durability will be affected by multiple physiological factors, resulting in bioprosthetic valve dysfunction. This dysfunction will be systematically classified into structural valve degeneration, non-structural valve degeneration, valve thrombosis, and infective endocarditis. The presentation will strictly adhere to the standardized Valve Academic Research Consortium-3 definitions. According to these criteria, bioprosthetic valve dysfunction will lead to bioprosthetic valve failure. The progression will be categorized into three distinct stages. Stage I will occur when the dysfunction becomes clinically manifest or when irreversible hemodynamic valve deterioration takes place. Stage II will be defined by the absolute necessity for an aortic valve reintervention. Finally, stage III will be documented in the event of a patient's death directly resulting from the bioprosthetic valve failure. A central component of the lecture will focus on structural valve degeneration, which will represent a primary mechanism of valve failure. Structural valve degeneration will involve intrinsic and structural changes within the bioprosthetic leaflets. These progressive alterations will include continuous wear and tear, leaflet disruption, flail leaflet mechanisms, fibrosis, progressive calcification, and strut fracture or deformation. These physical changes will occur in direct association with a progressive hemodynamic deterioration of the valve. He will emphasize that fully understanding the mechanistic underpinnings of structural valve degeneration will be of the utmost importance. This knowledge will be crucial for accurate patient risk stratification, the implementation of forward-looking therapeutic strategies, and the comprehensive lifetime management of younger demographics. Although clinical relevance will remain high, it will be noted that data regarding the exact predictors of structural valve degeneration will still require extensive future research. To provide concrete benchmarks, the presentation will project detailed comparative outcomes from landmark randomized controlled trials, contrasting transcatheter procedures with traditional surgical aortic valve replacement. These clinical trials will provide evidence to guide decision-making for future patients. First, the 10-year follow-up data from the NOTION trial, involving patients with a mean age of 79 years, will be reviewed. The findings will demonstrate that the incidence of severe structural valve degeneration will be significantly lower in the transcatheter group at 1.5 percent, compared to 10.0 percent in the surgical group. However, the overall rates of bioprosthetic valve failure will show no significant divergence between the two groups. Subsequently, the session will divide the 7-year follow-up results from the PARTNER III trial, which focused on a low-risk population with a mean age of 73. The projected data will indicate that the rates of Stage II and Stage III structural valve degeneration will remain comparable, at 7.3 percent for the transcatheter group and 7.6 percent for the surgical group. Furthermore, bioprosthetic valve failure rates will demonstrate parity at 6.9 percent and 7.3 percent, respectively. While valve thrombosis will be slightly higher in the transcatheter group at 2.8 percent versus 0.5 percent, these cases will largely resolve through standard anticoagulation therapies. The 5-year follow-up data from the Evolut Low Risk trial, encompassing patients with a mean age of 74, will further consolidate this landscape. Bioprosthetic valve dysfunction will be highly similar between the transcatheter group at 13.4 percent and the surgical group at 14.7 percent. Bioprosthetic valve failure will also be equivalent at 6.0 percent versus 5.6 percent. Notably, rates of patient-prosthesis mismatch and endocarditis will be lower with the transcatheter approach. A critical segment of the talk will then address a recently reported partial analysis from the 7-year follow-up of the Evolut trial. This analysis will reveal higher rates of reintervention with the transcatheter approach at 9.8 percent, compared to 6.0 percent for surgery, predominantly driven by aortic regurgitation. A post-hoc analysis will identify off-label post-dilation, specifically within the Evolut R 34mm valve, as the primary mechanical driver for this increased reintervention rate. A benchmark study will suggest that utilizing larger-than-recommended balloons will induce a spectrum of leaflet damage at the commissure level, ranging from microscopic tears to macroscopic ruptures. Despite these technical challenges, a deeply reassuring clinical observation will be emphasized. The requirement for reintervention will not be associated with an increased risk of mortality. The overall rates of death, stroke, or aortic valve-related hospitalization will remain remarkably similar between the transcatheter and surgical modalities. Concluding the session, he will firmly reiterate that transcatheter heart valve durability will be the absolute cornerstone for managing younger, lower-risk patients. Because robust data will remain limited at the mid-term mark, he will advocate that further data spanning at least a continuous 10-year follow-up will be strictly required before universally extending these transcatheter indications. Until then, the 5-year data for the Evolut-CoreValve platform and the 7-year data for the Sapien platform will confidently show that transcatheter durability will rival traditional surgery. Ultimately, this session will empower clinicians with the predictive knowledge required to optimize lifelong cardiovascular care in a rapidly advancing technological era. TCTAP Workshops Comprehensive TAVR Management Thursday, April 30, 8:30 AM ~ 10:00 AM Valve & Endovascular Theater, Level 1 Check the Session

April 30, 2026 206

TCTAP 2026

Tailored DAPT in High-Risk Complex PCI: Still a Theory in Search of Proof

At the scientific session, “Evolving Antiplatelet Therapy After PCI: Toward Safer and Smarter Strategies,” taking place on April 30 in Room 202, Davide Capodanno, MD (Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Italy) will address a central challenge in contemporary percutaneous coronary intervention (PCI): how to balance thrombotic protection against bleeding risk in patients undergoing complex or high-risk procedures. As PCI practice evolves, the traditional “one-size-fits-all” approach to dual antiplatelet therapy (DAPT) will increasingly give way to more individualized strategies. A key concept to be discussed will be the temporal modulation of antiplatelet therapy. This strategy will involve early intensification of platelet inhibition to reduce peri-procedural thrombotic risk, followed by later de-escalation to minimize bleeding complications. While biologically plausible, its clinical value will remain uncertain. The lecture will focus on the TAILORED-CHIP trial, the first randomized study evaluating this time-dependent approach in complex or high-risk PCI. A total of 2,018 patients were randomized to either a tailored regimen-ticagrelor plus aspirin for six months followed by clopidogrel monotherapy-or to standard DAPT with clopidogrel and aspirin for 12 months. The primary composite endpoint of death, myocardial infarction, stroke, stent thrombosis, urgent revascularization, or clinically relevant bleeding did not significantly differ between groups (10.5% vs. 8.8%; HR 1.19; P=0.21). These findings indicate that temporal tailoring does not provide a net clinical benefit compared with standard therapy, and their implications for current clinical practice will be discussed. The lecture will further examine key limitations of the study, including lower-than-expected event rates and the heterogeneity of the study population. These factors will be discussed in terms of their impact on statistical power and the interpretation of treatment effects. The findings will be placed in the context of prior evidence, including the ALPHEUS trial, as well as current recommendations from the European Society of Cardiology. The selective use of potent P2Y12 inhibitors and the importance of individualized decision-making will be emphasized. Finally, future research directions will be outlined. These will include the need for better patient selection, optimization of treatment timing, and the potential integration of precision medicine approaches such as genetic or biomarker-guided therapy. In summary, this lecture will review current evidence and ongoing uncertainties surrounding tailored DAPT in complex PCI. While the concept of time-dependent modulation remains promising, its clinical benefit has yet to be established, and further investigation will be required before routine implementation can be recommended. Kang DY, et al. European Heart Journal, https://doi.org/10.1093/eurheartj/ehaf652 TCTAP Workshops Evolving Antiplatelet Therapy After PCI: Toward Safer and Smarter Strategies Thursday, April 30, 8:30 AM ~ 9:50 AM Room 202, Level 2 Check the Session

April 30, 2026 232

COMPLEX PCI 2025

Stent Optimization After Class IA Indication of Imaging-Guided PCI in the 2024 ESC Guideline

In his COMPLEX PCI 2025 lecture entitled "Stent Optimization After Class IA Indication of Imaging-Guided PCI in the 2024 ESC Guideline," Myeong-Ki Hong, MD, PhD (Severance Hospital, Korea), emphasized that post-PCI minimum stent area (MSA) remains the most powerful determinant of clinical outcomes. Before the 2024 update, intravascular imaging was primarily recommended for complex PCI, with optimization encouraged but not strongly mandated. The 2024 ESC chronic coronary syndrome guidelines, however, have upgraded imaging-guided PCI to a Class IA recommendation, formally establishing intravascular imaging as standard of care. He stressed that this upgrade should not be interpreted as an endpoint, noting that imaging itself does not improve outcomes unless it translates into adequate stent optimization. Consistent with this concept, randomized trials such as IVUS-XPL and ULTIMATE demonstrated that PCI meeting IVUS-defined optimization criteria resulted in superior clinical outcomes compared with suboptimal PCI, even when imaging was used in both groups. Expert consensus documents describe multiple optimization targets after stent implantation, including minimum stent area, relative stent expansion, malapposition, tissue prolapse, edge dissection, and reference vessel disease. However, he pointed out that these criteria are often difficult to remember and apply in daily practice. He emphasized that an absolute post-PCI MSA threshold provides the most practical and clinically discriminative criterion. Across landmark trials, an MSA ≥5.5 mm² consistently showed the strongest ability to discriminate long-term clinical outcomes, supporting the concept that, among numerous optimization parameters, achieving an MSA ≥5.5 mm² represents the most reliable and clinically meaningful target for post-PCI optimization. He concluded that in the era of Class IA imaging guidance, the key question is no longer whether to use intravascular imaging, but how well stent optimization is achieved. Among numerous proposed parameters, post-PCI MSA remains the simplest and most clinically meaningful metric to remember, particularly in complex PCI. Live Case 1: Left Main & Multi-Vessel Disease Friday, November 28, 9:00 AM ~ 10:30 AM Main Arena Watch Session Video

January 2, 2026 14237

COMPLEX PCI 2025

Drug-Coated Balloons in Native Coronary Arteries: Hope or Hype?

At COMPLEX PCI 2025, Jung-Min Ahn, MD, PhD (Asan Medical Center, Korea), delivered a comprehensive overview of the current evidence for drug-coated balloons (DCBs) in native coronary artery disease in a lecture entitled "SELUTION, ALLIANCE, OCVC-BIF: DCB in Native Coronary Arteries—Hope or Hype?" DCBs are well established for the treatment of in-stent restenosis and have shown outcomes comparable to drug-eluting stents (DES) in small-vessel coronary disease. However, their role in native coronary arteries remains uncertain. He framed the discussion within the historical evolution of percutaneous coronary intervention, noting that the renewed interest in DCBs reflects a return to drug delivery without permanent metal implantation after decades of stent-based therapy. The REC-CAGEFREE I trial highlighted the limitations of DCB therapy in native coronary disease. In this randomized comparison of paclitaxel-coated balloons and contemporary DES for non-complex de novo lesions, DCB failed to meet non-inferiority at two years (Figure 1). Extended three-year follow-up demonstrated similar rates of cardiac death and target-vessel myocardial infarction between groups, but significantly higher rates of clinically and physiologically indicated target lesion revascularization in the DCB arm (Figure 2). Figure 1. Figure 2. In contrast, the SELUTION DeNovo trial evaluated a strategy of sirolimus-eluting balloon angioplasty with provisional stenting compared with systematic DES implantation. This large, investigator-driven trial randomized patients before lesion preparation and applied broad inclusion criteria. At one year, target vessel failure occurred in 5.3% of patients treated with the DCB strategy and 4.4% of those treated with DES, meeting the pre-specified non-inferiority criterion (Figure 3). Notably, approximately 80% of patients in the DCB strategy group avoided stent implantation, with low and comparable rates of major adverse cardiac events. Five-year follow-up is ongoing. He also reviewed real-world data from contemporary registries. The Swedish SCAAR registry suggested more favorable outcomes with bioadaptor strategies than with DCB in propensity-matched analyses (Figure 4). The GINGER study demonstrated feasibility of sirolimus-eluting balloons in complex de novo lesions but reported numerically higher event rates at one year (Figure 5). Conversely, the Japanese ALLIANCE registry showed favorable one-year outcomes with imaging-guided paclitaxel DCB PCI, emphasizing the importance of careful lesion preparation and routine intravascular imaging (Figure 6). Figure 3. Figure 4. Figure 5. Figure 6. In conclusion, he emphasized that DCB therapy in native coronary arteries should not be viewed as a universal alternative to DES. While early randomized trials underscored important limitations, newer device technologies and strategy-based approaches, such as those evaluated in the SELUTION DeNovo trial, suggest that DCBs may play a selective role in contemporary PCI practice. Ongoing dedicated trials in specific patient populations, including those with large-vessel disease and high bleeding risk, are expected to further clarify whether DCB strategies can achieve outcomes comparable to DES in native coronary artery disease. Special Session: TCT 2025 Hot Issues Thursday, November 27, 5:00 PM ~ 5:50 PM Main Arena Watch Session Video

January 2, 2026 701

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