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SEOUL VALVES 2025

TAVR Expectations for the Next Two Decades

At the 14th SEOUL VALVES 2025 meeting, held on August 7–8, Alan C. Yeung, MD (Stanford University School of Medicine, USA), presented “TAVR: Expectations for the Next Two Decades” during the Opening, Live Case & Lecture 1: TAVR session on August 7, delivering a detailed perspective on how transcatheter aortic valve replacement (TAVR) may progress over the next two decades. He began by tracing the evolution of interventional cardiology, comparing the maturation of drug-eluting stents (DES) — which achieved stability within about 18 years — to the still-developing trajectory of TAVR. Since the first procedure in 2002, TAVR indications have expanded from inoperable to low-risk patients, yet several challenges remain unresolved, including anatomical complexity, device limitations, and strategies for long-term durability and repeat interventions. Looking forward, he outlined potential innovations: valves engineered for 30–40 years of durability, smaller delivery profiles, 3D-printed patient-specific designs, AI-driven preoperative planning and intra-procedural guidance, and wearable sensors for continuous monitoring of valve function. A significant portion of the lecture addressed bicuspid aortic valve disease (BAVD), emphasizing that suboptimal transcatheter heart valve (THV) expansion in this setting is linked to poorer clinical outcomes. To address this, recent advances such as mechanical leaflet splitting (ShortCut™) and intentional leaflet laceration (BASILICA) were discussed as strategies to improve valve expansion, optimize annular sizing, and reduce procedural risks in complex anatomies. He also reviewed the expanding role of TAVR in treating aortic regurgitation and in valve-in-valve (ViV) procedures. These indications present unique technical challenges, including anchoring in non-calcified annuli, limited fluoroscopic visualization, and the prevention of coronary obstruction. In this context, he emphasized the importance of lifetime management of aortic valve disease, noting that the choice of the first THV can significantly impact future procedural options. The session concluded with an outlook toward achieving the “one valve for life” concept, supported by next-generation synthetic polymers and novel tissue-processing methods designed to overcome current durability limitations in bioprosthetic valves. Opening, Live Case & Lecture 1: TAVR Thursday, August 7, 10:00 AM-12:00 PM Main Arena, B2 Watch Session Video

August 22, 2025 925

SEOUL VALVES 2025

Minimally Invasive SAVR Gains Ground at Asan Medical Center, Combining Safety With Faster Recovery

SEOUL, South Korea—At the 14th SEOUL VALVES 2025 meeting, Joon Bum Kim, MD, PhD (Asan Medical Center, University of Ulsan College of Medicine, Korea), delivered an update on his center’s 25-year experience with surgical aortic valve replacement (SAVR), showing that minimally invasive approaches are steadily replacing conventional full sternotomy in routine practice. With adoption rates climbing from less than 20% before 2019 to 52% by 2025 for the right anterior thoracotomy (RAT) approach alone, he says the data—both global and institutional—provide a compelling case for change. “We are moving toward a far more convenient and less invasive approach,” he told attendees, noting that incisions are now typically 5 cm or smaller, without rib cutting, and in some centers abroad can be reduced to just 3 cm with thoracoscopic or robotic assistance. Global Evidence: Less Trauma, Comparable Safety He began with a review of the international literature. A meta-analysis of 14 randomized controlled trials (RCTs) involving 1,395 patients compared full sternotomy with mini-sternotomy and found no statistical difference in early mortality. However, minimally invasive approaches offered significant advantages in shorter hospital stays, less blood loss, lower pain scores, and improved quality of life. He then pointed to a large observational study from 10 centers in Italy and Germany involving nearly 6,000 patients—propensity-matched to create roughly 2,200 balanced pairs—which included both mini-sternotomy and thoracotomy. In that analysis, minimally invasive approaches reduced 30-day mortality by 37% compared with full sternotomy (OR 0.63; 95% CI 0.43–0.93; p=0.021). Importantly, this survival benefit was consistent across hospitals and surgeons regardless of case volume. The Asan Experience: Strong Alignment With Global Trends From 2000 to April 2025, Asan Medical Center performed 2,437 isolated SAVR procedures, 937 of them in the past five years. Overall, unadjusted 30-day mortality was 0.36% for minimally invasive surgical aortic valve replacement (MICS SAVR) compared with 1.02% for conventional full sternotomy. A detailed propensity-score matched analysis compared three groups—full sternotomy, mini-sternotomy, and RAT—each with 281 patients. Procedural times were longer in the minimally invasive groups, but early outcomes were statistically similar: Early Mortality: 0.0% for full sternotomy, 0.4% for mini-sternotomy, and 0.7% for RAT (p=0.36) Bleeding Reoperation: No significant difference (p=0.20) Disabling Neurological Events: No significant difference (p>0.99) Interestingly, patients selected for minimally invasive approaches at Asan were on average older and had more comorbidities, including higher rates of diabetes, dyslipidemia, chronic lung disease, and end-stage liver disease—yet maintained comparable safety profiles. Quality-of-Life Benefits and Surgeon Experience Although quality-of-life and pain data for SAVR patients were not directly measured in this analysis, he referenced Asan’s separate study of more complex aortic arch surgery showing that mini-access approaches significantly lowered pain scores and shortened hospital stays. “I strongly believe these benefits apply to surgical AVR as well,” he said. Surgeon experience remains a key factor in success. At Asan, four large-volume surgeons perform 69% of all SAVR cases, with some exceeding 90% MICS use. This concentration of expertise has enabled a steady transition toward minimally invasive techniques. “Despite high surgeon-dependent variation in practice pattern, large-scale meta-analysis and multi-center data indicate that MICS SAVR probably enhances clinical outcomes,” he emphasized. A Technique Poised for Wider Adoption For him, the case is clear: minimally invasive SAVR offers a safe, effective, and patient-friendly alternative to conventional surgery—particularly in experienced hands. “Our data go well with recent findings, with promising results,” he concluded, adding that the approach’s advantages in recovery and comfort could help it become a new standard for suitable patients worldwide. Keynote Session: Cutting-Edge Innovations in Valve Therapies II Friday, August 8, 1:00 PM-2:00 PM Main Arena, B2 Watch Session Video

August 22, 2025 870

TCTAP 2025

IVUS or OCT in Bifurcation PCI: Is There a Gold Standard?

At TCTAP 2025, in the breakfast session of 'Imaging & Physiology I', Imad Sheiban, MD (Pederzoli Hospital, Italy), addressed the evolving role of intravascular imaging in bifurcation PCI. He emphasized that angiography alone is often insufficient to guide complex bifurcation interventions. Instead, intravascular ultrasound (IVUS) and optical coherence tomography (OCT) have become essential tools to evaluate plaque composition, lesion morphology, and optimize procedural results. IVUS and OCT provide valuable insights such as vessel sizing, plaque burden, stent expansion, malapposition, edge dissection, and side branch jailing. Longitudinal vessel imaging can also help predict carinal shift and side branch compromise. He illustrated how OCT’s superior resolution detects subtle stent malapposition and edge dissections, whereas IVUS offers better vessel wall visualization in larger vessels. Recent randomized trials and meta-analyses, including the OCTOBER and OCTIVUS studies, have confirmed that both IVUS- and OCT-guided bifurcation PCI improve clinical outcomes compared to angiography guidance alone. Both modalities are safe and effective, with no clear superiority. In conclusion, he noted that the decision to use IVUS or OCT should be individualized based on clinical context, lesion complexity, and operator experience. “The use of intravascular imaging must be incorporated into daily practice for optimal bifurcation PCI outcomes,” he stated. Imaging & Physiology I Thursday, April 24, 7:00 AM-8:00 AM Presentation Room 1, Level 1 Check The Session

June 05, 2025 2132

TCTAP 2025

Bifurcation PCI Strategy After ISCHEMIA: Don’t Touch Small Side Branch!

At TCTAP 2025, during the "Bifurcation PCI: New Concept and Approaches" session, Seung-Jung Park, MD, PhD (Asan Medical Center, Korea), delivered a lecture redefining the approach to bifurcation PCI in the wake of the ISCHEMIA study. Focusing on both non-left main (non-LM) and left main (LM) bifurcation lesions, he emphasized that these two entities demand fundamentally different strategies—simplification for the former, and individualized precision for the latter. His message for non-LM bifurcation was clear and bold: “Don’t touch small side branches.” Citing results from the ISCHEMIA trial and subsequent meta-analyses, he emphasized that percutaneous coronary intervention (PCI) confers no survival advantage over optimal medical therapy (OMT) in stable ischemic heart disease—even in patients with multivessel disease or severe ischemia. This shift in philosophy calls for a more judicious and physiology-driven approach to PCI, especially in bifurcation settings. In non-LM bifurcations, over 80% of side branches were found to supply less than 10% of the myocardial mass. These "small" branches—defined as those with a reference vessel diameter 2.5 mm)—especially in true bifurcation lesions (Medina 1,1,1 or 0,1,1)—he advocated upfront two-stent strategies. Still, he underscored that unnecessary treatment of jailed side branches, even when angiographically narrowed, should be deferred unless functionally significant. For LM bifurcations, he clarified that a separate strategy is warranted. Unlike non-LM lesions, LM disease often involves larger branches with substantial myocardium at risk. Here, intravascular imaging and FFR play pivotal roles in guiding one- versus two-stent strategies. When the left circumflex artery (LCX) is large and disease is truly bifurcated, upfront two-stenting is justified and can reduce the risk of side branch occlusion without compromising outcomes. He concluded by summarizing his clinical rules: Don’t touch small side branches (

June 05, 2025 1982

TCTAP 2025

FFR-Guided PCI Matches CABG in Long-Term Outcomes

In the “Late-Breaking Clinical Trials 2025” session at TCTAP 2025, William F. Fearon, MD (Stanford University, USA), presented the final 5-year results of the FAME 3 trial, showing that fractional flow reserve (FFR)-guided PCI delivers comparable long-term outcomes to coronary artery bypass grafting (CABG) in patients with three-vessel coronary artery disease. CABG has long been considered the gold standard for multivessel coronary artery disease, with previous studies consistently demonstrating its long-term superiority over PCI. But according to him, most of that data is outdated. FAME 3 trial was designed to reflect contemporary clinical practice, incorporating advanced stent technologies, physiology-guided PCI, and optimal medical therapy. The FAME 3 trial enrolled 1,500 patients across 48 centers worldwide, randomizing them to receive either FFR-guided PCI with contemporary drug-eluting stents or angiography-guided CABG. Importantly, both groups received optimal medical therapy, with high rates of statin, antiplatelet, beta-blocker, and RAS inhibitor use. At five years, the composite endpoint of death, stroke, or MI occurred in 16% of PCI patients and 14% of CABG patients (HR 1.16, 95% CI 0.89–1.52; p=0.27) (Figure). Landmark analysis indicated that the early advantages of CABG did not extend beyond the first year. Mortality was identical in both arms at 7.2%. While the stroke rate was numerically lower with PCI (1.9% vs. 3%), MI (8.2% vs. 5.3%) and repeat revascularization (15.6% vs. 7.8%) occurred more frequently in the PCI group (Table). “Despite higher rates of MI and repeat revascularization, we found no difference in the hard endpoint of death, stroke, or MI at 5 years between FFR-guided PCI and CABG,” he said. “This marks a notable shift from previous trials. There was no late accrual of benefit with CABG after the first year.” Subgroup analysis based on SYNTAX score revealed significant interaction: patients with low (

May 30, 2025 1954

TCTAP 2025

Left Main and Multi-Vessel Revascularization 2025: Updated Guidelines and Beyond

At TCTAP 2025, during the "Left Main & Multi-Vessel: Updated Practice and New Concept" session, Gregg W. Stone, MD (Mount Sinai, USA), presented the 2025 updated guidelines on coronary revascularization, focusing on left main and multivessel disease. Reflecting recommendations from major U.S. cardiovascular societies, the new guidance emphasizes both clinical evidence and patient-centered decision-making. For symptomatic patients, revascularization (PCI or CABG) is a Class I recommendation to relieve angina when medical therapy fails. PCI becomes a reasonable option (Class IIa) in patients unsuitable for surgery. In left main disease, CABG is recommended for high-complexity cases due to survival benefits. When PCI can achieve equivalent revascularization, it may be reasonable in low-to-moderate complexity settings. Contrary to expectations, diabetes did not significantly alter outcomes in left main disease, though complexity (measured by SYNTAX score) did show impact, with CABG favored in high-risk cases. For multivessel disease, pooled trial data reveal a modest mortality benefit for CABG over PCI—especially in diabetics, where the difference reaches 5.5%. Non-diabetic patients show no significant mortality difference. A consistent more stroke risk (~1%) with CABG remains a consideration. He referenced trials like SYNTAX, EXCEL, and FAME 3. While early benefits of CABG were noted, long-term outcomes—such as death, stroke, and MI—tended to converge. The FAME 3 trial showed PCI and CABG have similar long-term results in triple-vessel disease. In patients with left ventricular dysfunction, CABG showed a survival benefit in the STICH trial. However, this was not replicated in the smaller REVIVED-BCIS2 trial, highlighting variability in results depending on study size, duration, and patient characteristics. He closed by stressing the importance of shared decision-making. “For many patients, outcomes between PCI and CABG are very similar,” he noted. “Preferences, comorbidities, and anatomy should all guide the final treatment plan.” Left Main & Multi-Vessel: Updated Practice and New Concept Friday, April 25, 8:30 AM-9:40 AM Coronary Theater, Level 1 Check The Session

May 30, 2025 1834

TCTAP 2025

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

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

May 23, 2025 1753

TCTAP 2025

Transcatheter Mitral Valve Intervention: Exploring the Future of TMVI Therapies

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

May 23, 2025 1115

TCTAP 2025

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

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

May 16, 2025 1071

TCTAP 2025

Lessons Learned from EARLY TAVR Trial

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

May 16, 2025 966

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