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TCTAP 2024

Severe AS with Low Valve Calcium Score: Different Prognosis?

Yeonwoo Choi, MD (Changwon Hanmaeum Hospital, Korea), explored severe aortic valve stenosis (AS) with low aortic valve calcification (AVC) score and its different prognosis at TCTAP 2024 on April 27. He stressed that patients with low AVC exhibit distinct clinical characteristics and a higher risk of long-term mortality compared with those with high AVC. Degenerative AS is characterized by excessive valvular calcification, which is also implicated in the hemodynamic progression of AS. Due to the possibility of discordance in echo parameters, AVC score was proposed as a diagnostic algorithm. Approximately 20% of the patients with discordant echo parameters had AVC scores below threshold (Figure 1). Figure 1. Threshold identifying severe aortic stenosis To analyze the prognosis and characteristics of severe AS with low AVC, a total of 1,002 patients were enrolled from the ASAN-AVR registry, a prospective, single-center, real-world registry including all consecutive patients who had undergone surgical or transcatheter aortic valve replacement. 1 in 4 patients with severe degenerative AS had an AVC lower than the proposed threshold for the diagnosis of severe AS. Those with low AVC were more likely to be female, receive hemodialysis, be younger, and had less LV remodeling. During a median follow-up period of 3.8 years, patients with low AVC had a significantly higher risk of all-cause mortality (Figure 2, 3). Figure 2. Clinical outcomes of patients with low and high AVC from the ASAN-AVR registry Figure 3. Hazard ratio of all-cause mortality and MACE by AVC quartiles He pointed out that women had a larger fibrotic component and a smaller calcification component compared to men, and these non-calcified tissues or fibrosis may be the cause of development and progression of AS, considering that several studies on aortic valve tissue volume and composition showed that non-calcific tissue volume was associated with cardiovascular events after TAVR. Meanwhile, there may be other pathophysiological mechanisms in the development and progression of AS that are not fully explained by calcification (Figure 4). He concluded that approximately 1 in 4 patients with severe AS have low AVC and these patients are at a higher risk of long-term mortality. Further research is needed to understand the pathogenesis and progression of low AVC AS. Figure 4. Characteristics and prognosis of patients with low AVC and high AVC Clinical Science All About New Data from Asan Medical Center Saturday, April 27, 10:05 AM ~ 11:25 AM Presentation Room 1, Level 1 Check The Session

June 04, 2024 801

TCTAP 2024

Impact of Intravascular Imaging-guided PCI or CABG in Multi-Vessel Disease: The BEST Extended Follow...

Jinho Lee, MD Kyung Hee University Hospital, Republic of Korea A recent post-hoc analysis of the BEST extended follow-up study shed new light on the efficacy of intravascular ultrasonography (IVUS) guided percutaneous coronary intervention (PCI) with everolimus-eluting stents (EESs) compared to bypass surgery for patients with multivessel coronary artery disease (CAD). Previous research (IVUS-XPL, ULTIMATE, and RENOVATE-COMPLEX-PCI trials) has shown that intravascular imaging-guided PCI improves clinical outcomes compared to coronary angiography (CAG)-guided PCI for cases of complex CAD. While both the American and European guidelines recommend IVUS-guided PCI as a class IIa intervention, coronary artery bypass grafting (CABG) remains the preferred option for patients with multivessel CAD, due to its perceived survival advantage. To address the question of whether the improved outcomes associated with IVUS-guided PCI could challenge the status of CABG in multivessel CAD, the researchers conducted an analysis of patient data from the BEST extended trial. This prospective, open-label, multicenter, randomized trial enrolled a total of 880 patients with multivessel disease over a 5-year period, randomly assigning them to either PCI with EESs or CABG. The median follow-up period was 11.8 years. The total patient population was categorized according to their treatment modalities into 3 groups: IVUS-guided PCI, CAG-guided PCI, and CABG (Figure 1). The primary endpoint was a composite of death from any cause, myocardial infarction, or target-vessel revascularization. Figure 1. Study design of the sub-study of BEST extended trial Notably, the CABG group had a higher rate of three-vessel disease, while the IVUS-guided PCI group had a higher incidence of two-vessel disease. Procedural characteristics varied across the groups, with complete revascularization more frequently achieved in the CABG group. However, the IVUS-guided PCI group had a longer total stent length and a larger stent diameter compared to the angiography-guided PCI group. Analyses of the primary composite endpoint and other key outcomes revealed that the IVUS-guided PCI group and the CABG group had similar event rates, both lower than the angiography-guided PCI group (Figure 2). Multivariable analysis adjusted for baseline imbalances confirmed these findings, indicating that IVUS-guided PCI is a safe and effective alternative to CABG for patients with multivessel disease. In conclusion, the study advocates a routine use of intravascular imaging during PCI for multivessel CAD, suggesting that IVUS-guided PCI offers comparable outcomes to CABG. Figure 2. Primary composite endpoint of the sub-study of BEST extended trial Clinical Science All About New Data from Asan Medical Center Saturday, April 27, 10:05 AM ~ 11:25 AM Presentation Room 1, Level 1 Check The Session

June 04, 2024 747

TCTAP 2024

Rule of 5-6-7-8 for Bifurcation PCI: It Is Time to Change in 2024

At TCTAP 2024, Jung-Min Ahn, MD, PhD (Asan Medical Center, Korea), presented compelling new criteria for optimizing left main (LM) coronary artery stenting. Traditionally, intravascular ultrasound (IVUS) guidance has been recommended to enhance clinical outcomes in LM procedures, highlighted by the well-known "5-6-7-8" criteria developed at Asan Medical Center. This standard, primarily predictive of angiographic restenosis, has been a benchmark in the field. A recent study scrutinizes the adequacy of these existing recommendations, focusing on the relationship between stent expansion in LM bifurcation and long-term clinical outcomes. He conducted a comprehensive analysis of 292 patients who underwent LM two-stenting with crush technique. The study identified the minimal stent area (MSA) at various segments within the LM bifurcation—11.8 mm² at the distal LM, 8.3 mm² at the ostial left anterior descending (LAD), and 5.7 mm² at the ostial circumflex—which are crucial for predicting clinical outcomes, including major adverse cardiac events (MACE). The findings compellingly suggest that while the distal LM's MSA did not significantly predict clinical outcomes, the MSA at the ostia of LAD and circumflex independently predicted outcomes, marking them as critical areas for ensuring adequate stent expansion. Those in the under-expansion group exhibited notably poorer outcomes, further emphasizing the need for precise stent placement and expansion. In another research, conducted on a large cohort of 879 patients at Asan Medical Center from March 2005 to September 2022, sought to validate the efficacy of IVUS in patients who underwent LM single-stent with crossover. The study identified the MSA from LM to LAD—11.4 mm² at the proximal LM, 8.3 mm² at the distal LM, and 8.1 mm² at the ostial LAD. Importantly, these two studies propose a shift from the "5-6-7-8" to a "6-8-11" criteria, which better correlates with the observed clinical outcomes in LM PCI (Figure 1). Figure 1. New IVUS MSA for LM bifurcation stenting His findings highlighted the importance of ensuring maximal MSA, as stent under-expansion was significantly associated with adverse long-term outcomes. The new criteria aim to establish more rigorous standards to ensure better clinical outcomes. The presentation concluded with a strong endorsement of intracoronary imaging as a pivotal tool for optimizing stent placement. It was emphasized that while imaging itself does not directly correlate with better outcomes, strategic use of this technology to guide stent placement contributes significantly to improved patient and stent outcomes. This session not only provided invaluable insights into the technical aspects of LM PCI but also reinforced the importance of ongoing research and adaptation of techniques in the interventional cardiology field. TCTAP Workshops New Concept of Bifurcation PCI Thursday, April 25, 4:00 PM ~ 5:40 PM Valve & Endovascular Theater, Level 2 Check The Session

May 30, 2024 910

TCTAP 2024

Timing of Complete Revascularization With Multi-Vessel PCI for AMI: Insights From the COMPLETE Trial...

At TCTAP 2024 on April 26, Shamir R. Mehta, MD (Hamilton General Hospital, Canada), explored the optimal timing of non-culprit lesion intervention of complete revascularization of multivessel disease and acute coronary syndrome. The benefit of complete revascularization over culprit-lesion-only percutaneous coronary intervention (PCI) was consistent, irrespective of the timing of non-culprit lesion intervention. The large, multi-center, randomized COMPLETE (Complete vs Culprit-only Revascularization to Treat Multi-vessel Disease After Early PCI for STEMI) trial showed that staged non-culprit lesion PCI with the goal of complete revascularization resulted in a significant reduction of the primary composite outcomes of cardiovascular (CV) death or new myocardial infarction (MI) and the composite of CV death, new MI or ischemia-driven revascularization (IDR), compared with culprit-lesion only PCI (Figure 1). Figure 1. Primary outcomes of COMPLETE trial Of the COMPLETE trial patients, 2,700 patients underwent PCI during the index hospitalization, and 1,300 patients underwent PCI after discharge. For patients in whom PCI was conducted during the index hospitalization, the hazard ratio (HR) was 0.77 for the hard clinical outcomes of CV death or new MI, and the median time to PCI was 1 day. Alternatively, if PCI was performed after the index hospitalization, the median time to PCI was 23 days and the HR was 0.69 (Figure 2). Figure 2. Effect of timing of PCI on the occurrence of CV death or new MI He emphasized that the event rates for both groups were very similar during the index hospitalization and after the initial hospitalization and that the benefits of complete revascularization of non-culprit lesions were similar regardless of the timing of non-culprit lesion intervention. Through landmark analysis, it was shown that the benefit of complete revascularization was primarily seen in long-term clinical outcomes (Figure 3, 4). Figure 3. Occurrence of CV death, MI or IDR over 4 years of follow-up Figure 4. Benefit of complete revascularization over longer term Meet the Experts Over Breakfast Left Main & Multi-Vessel PCI: Now and Future Friday, April 26, 7:30 AM ~ 8:25 AM Main Arena, Level 2 Check The Session

May 30, 2024 837

TCTAP 2024

Moderate AS in HFrEF: Time to Treat is Now & Future Expectation from RCT

Patients with aortic stenosis (AS) have a high mortality risk across all levels of AS severity. Nicolas M. Van Mieghem, MD (Erasmus University Medical Center, Netherlands), commented that any degree of AS is clinically relevant, and emphasized the role of cardiac remodeling, fibrosis, and dysfunction in the natural history of patients with AS, which yields high residual risk after aortic valve replacement (AVR). Currently, AVR is only formally indicated for symptomatic, severe AS. However, optimal timing of intervention in patients with moderate AS remains controversial. He mentioned that patients with concomitant moderate AS and left ventricular (LV) systolic dysfunction are also at high risk for clinical events such as death, AVR, or heart failure (HF) hospitalization, raising questions whether earlier AVR in these patients could improve clinical outcomes. Several studies have shown that patients with moderate AS and LV dysfunction are associated with a poor prognosis, as are patients with symptomatic AS. Transcatheter AVR (TAVR) can provide mechanical LV unloading in patients with HF and moderate AS. Based on the multinational ATLAS TAVI registry, patients with non-severe AS and reduced left ventricular ejection fraction had better survival with TAVR than with medical treatment. These results suggest the need for randomized controlled trials comparing TAVR versus medical treatment in patients with moderate AS and HF with reduced ejection fraction (HFrEF). Meanwhile, risk stratification approaches considering the presence of extra-aortic cardiac damage (i.e., LV, left atrial or mitral valve damage, pulmonary or tricuspid valve damage, right ventricular damage or subclinical HF) have also been studied, which may be helpful to identify asymptomatic AS patients who may benefit from elective AVR. Several clinical trials are currently underway to answer the question of whether early AVR for moderate AS in the setting of HFrEF interrupts maladaptive cardiac remodeling and improves clinical outcomes. Among them, the results of TAVR UNLOAD trial (ClinicalTrials.gov: NCT02661451) are expected in 2024 (Figure 1). The PROGRESS trial (ClinicalTrials.gov: NCT04889872) and the Evolut™ EXPAND TAVR II pivotal trial (ClinicalTrials.gov: NCT05149755) will also provide valuable insights on the moderate AS population. Figure 1. Pathophysiologic rationale for the TAVR UNLOAD trial Meet the Experts Over Breakfast TAVR: Techniques and Issues Friday, April 26, 7:30 AM ~ 8:25 AM Presentation Room 1, Level 1 Check The Session

May 30, 2024 652

TCTAP 2024

How Can We Further Improve Reperfusion in AMI?: Revising or Novel Approach

In a captivating presentation at TCTAP 2024 in Incheon, Korea, Adrian P. Banning, MD (Oxford University Hospitals NHS Foundation Trust, United Kingdom), illuminated the current landscape of reperfusion therapy in acute myocardial infarction (MI), with a particular focus on the outcomes of intermittent coronary sinus occlusion. Despite technological strides enhancing the efficacy of reperfusion therapy post-acute MI, outcomes have been stagnant since the early 2000s. Cardiologists worldwide acknowledge their unwavering dedication to patient care yet recognize the persistent need for improved clinical outcomes in acute MI cases. Countless clinical trials have endeavored to evaluate novel devices and approaches to better prognoses, yet many have failed due to inefficacy. While the current standard treatments yield favorable results in approximately 60-70% of ST-segment elevation myocardial infarction (STEMI) patients, the crux lies in individualized care. Each patient presents with unique comorbidities and socioeconomic factors, necessitating tailored approaches within the framework of standard management protocols. The size of the infarct is a pivotal determinant of clinical outcomes post-acute MI. Extensive research underscores a direct correlation between larger infarct sizes and worsened clinical prognoses. Meta-analyses have elucidated this relationship, showing mortality and heart failure (HF) hospitalization rates escalating alongside increasing infarct sizes. Various validated tools have emerged to refine outcome prognostication. Microvascular occlusion, detected via cardiac magnetic resonance imaging (CMR) post-percutaneous coronary intervention (PCI), stands out as a robust predictor of mortality and HF hospitalization within one year. Additionally, the index of microcirculatory resistance (IMR) has emerged as an early discriminator, with post-PCI IMR values exceeding 40 signaling adverse outcomes in the catheterization laboratory. Recent advancements, such as angiography-derived IMR, leveraging computational flow dynamics for 3D vessel modeling, exhibit a promising correlation with wire-based IMR measurements. In light of these advancements, he unveiled findings from the pressure-controlled intermittent coronary sinus occlusion (PiCSO)-AMI-I trial, evaluating the clinical efficacy of intermittent coronary sinus occlusion. Enrolling 145 STEMI patients, the trial randomized participants to conventional PCI or PiCSO-assisted PCI. Disappointingly, the primary endpoint of infarct size at 5 days by CMR failed to exhibit significant differences between groups despite prolonged PCI durations and increased radiation and radiocontrast exposure (Figure 1). Similarly, clinical outcomes remained unaltered. Figure 1. Result of the primary endpoint of PiCSO-AMI-I trial As pursuing enhanced outcomes in acute MI treatment persists, these findings underscore the necessity for continued exploration and innovation within reperfusion therapy paradigms. Meet the Experts Over Breakfast ACS and Acute MI: Brand New Issues Saturday, April 27, 7:30 AM ~ 8:25 AM Presentation Room 2, Level 1 Check The Session

May 30, 2024 657

TCTAP 2024

Revascularization for Left Main Disease: Updated Data, Global Guideline and Beyond

During a recent lecture at Asan Medical Center, Seung-Jung Park, MD, PhD (Asan Medical Center, Korea), shared critical updates on revascularization for left main (LM) coronary artery disease, incorporating global guidelines and innovations beyond traditional methods. His discussion, based on significant clinical research and trials such as SYNTAX, PRECOMBAT, NOBLE, and EXCEL, focused on the relative merits of percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG). He presented findings from a meta-analysis of 4,394 patients, which indicated that over a decade, there was no notable difference in all-cause mortality between PCI and CABG arms. These results highlight the intricate decision-making process in selecting the appropriate revascularization strategy, influenced by the coronary complexity assessed by the SYNTAX score (Figure 1). Figure 1. Candidates for PCI in those with left main disease, based on the 2018 ESC guideline. The lecture also delved into the significance of physiological and imaging techniques in enhancing PCI outcomes. He stressed the importance of tools such as fractional flow reserve and intravascular ultrasound, which are essential for a more accurate clinical assessment and revealing the functional severity of coronary lesions that angiography might overlook. In discussing technological advancements, evolving PCI methods were mentioned, including dual stenting for complex bifurcation lesions, which showed promise in keeping vessels open and reducing restenosis. Such advancements are indicative of a shift towards more precise and individualized approaches in managing LM disease, aligning with the principles of personalized medicine. Furthermore, he emphasized the need for tailored revascularization strategies that consider each patient's unique anatomical and comorbidity profiles to maximize treatment outcomes. This approach underscores a substantial shift in the treatment paradigm for LM coronary artery disease, moving away from traditional surgical methods. The concluding message, "LM Disease is Not a Surgical Disease Anymore!" indicates a significant turning point in the field. The progress in imaging and physiology-guided PCI has greatly enhanced clinical outcomes, proving that non-surgical methods are not only feasible but also highly effective. Particularly, the strategy of deploying upfront dual stents in cases of true bifurcation has been shown to be both safe and beneficial. This approach reflects the ongoing refinement in interventional cardiology, where precise, tailored treatments enhance patient recovery and long-term health, steering away from more invasive surgical options. TCTAP Workshops Left Main and Multi-Vessel Diseases: Updated Concept and Treatment Thursday, April 25, 2:00 PM ~ 3:50 PM Valve & Endovascular Theater, Level 2 Check The Session

May 21, 2024 924

TCTAP 2024

Choosing Wisely: FFR vs. Anatomy-guided Left Main PCI -The Rationale of the FATE-MAIN Trial

A recent lecture by Do-Yoon Kang, MD, PhD (Asan Medical Center, Korea), at TCTAP 2024, ‘Left Main and Multi-Vessel Diseases: Updated Concept and Treatment’ elucidated the evolving landscape of diagnosing and treating significant stenosis in Left main coronary artery (LMCA) disease. The definition of a significant left main disease varies, with thresholds set by major trials, such as the PRECOMBAT and EXCEL trials (Figure 1). While the PRECOMBAT trial identified significant disease at a threshold of 50% in terms of diameter stenosis, as estimated visually, the EXCEL trial defined significant stenosis as 70%, incorporating functional assessments for diameter stenosis between 50% and 70%. Some past trials have shown surgical benefits for patients with left main disease with a diameter stenosis of over 50% or 70%. However, challenges persist due to the poor reproducibility of angiographic analysis in assessing LMCA stenosis. In turn, intracoronary imaging combined with fractional flow reserve (FFR) has been offered as a solution, with data supporting its use in equivocal cases. Also, the 2018 ESC guideline recommends considering intravascular ultrasound (IVUS) to assess the severity of unprotected left main lesions. Meanwhile, discrepancies remain in FFR and IVUS-minimal luminal area (MLA) in intermediate LMCA stenosis. Figure 1. Definition of Significant Left Main Disease In this clinical context, the upcoming FATE-MAIN (Fractional Flow Reserve versus Angiography for Treatment-Decision and Evaluation of Significant Left Main Coronary Artery Disease) trial was announced, comparing outcomes of FFR-guided percutaneous coronary interventions (PCI) against angiography-guided interventions (Figure 2). The study aims to enroll 934 patients, and the primary endpoint will be the composite of death from any causes, myocardial infarction, or hospitalization for unstable angina, heart failure, resuscitated cardiac arrest, or repeat revascularization at 2 years. The lecture concluded with a message that achieving complete functional revascularization is important, and for all borderline or intermediate LMCA disease it is strongly recommended to confirm physiologic lesion significance before treatment using FFR evaluation. It is anticipated that FATE-MAIN will show better patient outcomes with FFR-guided PCI by avoiding unnecessary interventions. Figure 2. Study Design of the FATE-MAIN Trial TCTAP Workshops Left Main and Multi-Vessel Diseases: Updated Concept and Treatment Thursday, April 25, 2:00 PM ~ 3:50 PM Valve & Endovascular Theater, Level 2 Check The Session

May 21, 2024 795

TCTAP 2024

Implications of the ISCHEMIA Trial on Patient Selection for CTO-PCI

At TCTAP 2024 in Incheon, Korea, Sripal Bangalore, MD (New York University Grossman School of Medicine, USA), delved into the implications of the ISCHEMIA Trial on patient selection for chronic total occlusion percutaneous coronary intervention (CTO-PCI). Historically, three major CTO trials, EXPLORE, EURO-CTO, and DECISION-CTO, have compared invasive and conservative treatments. Each of these trials failed to demonstrate a significant benefit in clinical outcomes, including death or myocardial infarction (MI) at 5 years. He presented the results of the landmark ISCHEMIA Trial, which randomized 5,179 patients with stable angina and significant MI to either conservative or invasive treatment. Primary and secondary endpoints did not differ significantly between the two groups. Although mortality rates were similar, the invasive treatment arm exhibited reduced incidences of spontaneous MI, unstable angina, and cardiovascular-related hospitalizations. Additionally, symptomatic patients experienced faster and more sustained relief from angina with invasive treatment. To address the question regarding the role of PCI in CTO management, he introduced the ISCHEMIA Trial CTO sub-study. This sub-study included 1,470 CTO patients identified via coronary computed tomography angiography (CCTA) and compared them with non-CTO counterparts. CTO patients tended to be younger with a higher prevalence of prior MI and heart failure, as well as moderate to severe ischemia on stress imaging. Clinical outcomes revealed inferior results for CTO patients, with higher rates of primary endpoints and cardiovascular mortality. Moreover, a comparison of conservative and invasive treatments within CTO or non-CTO groups yielded similar primary endpoint outcomes, with lower incidences of spontaneous MI observed in the invasive treatment arms, mirroring the overall ISCHEMIA trial findings (Figure 1). Figure 1. Outcomes by treatment group and CTO status in ISCHEMIA Trial CTO sub-study Concluding the lecture, he underscored the importance of treatment strategies for CTO patients. Drawing insights from all CTO trials and the ISCHEMIA CTO sub-study, the implementation of aggressive guideline-directed medical therapy was advocated for all CTO patients. Furthermore, judicious consideration of invasive treatment was suggested to enhance angina-related quality of life and mitigate the risk of spontaneous MI. TCTAP Workshops CTO-PCI: To Treat, or Not To Treat Thursday, April 25, 10:30 AM ~ 12:22 PM Valve & Endovascular Theater, Level 2 Check The Session

May 21, 2024 740

TCTAP 2024

ASSURE-DES Trial: Optimal Antiplatelet Strategy in DES Patients During Noncardiac Surgery

Hanbit Park, MD GangNeung Asan Hospital, Korea The management of antiplatelet therapy in patients who need noncardiac surgery after percutaneous coronary intervention (PCI) with drug-eluting stents (DESs) requires consideration, including the risks of stent thrombosis with cessation and bleeding with continuation. The current guideline recommends continuation of aspirin perioperatively if the bleeding risk allows. However, for patients undergoing surgery with high bleeding risk (e.g. intracranial, spinal neurosurgery, or vitreoretinal ophthalmic surgery), discontinuation of aspirin is recommended at least 7 days preoperatively. There are limited data on continuation of aspirin in patients with prior PCI with DES who are undergoing noncardiac surgery. The subgroup analysis of POISE-2 trial showed that in patients with prior PCI, continuation of aspirin reduced the risk of death or non-fatal myocardial infarction (MI) (hazard ratio [HR] 0.50; 95% confidence interval [CI] 0.26-0.95). The risk for major or life-threatening bleeding was neutral (HR 1.26; 95% CI 0.55-2.88). However, this study was underpowered and does not exclude a potential subgroup effect, as it was a subgroup analysis. Perioperative Antiplatelet Therapy in Patients With Drug-eluting Stent Undergoing Noncardiac Surgery (ASSURE-DES) trial is an investigator-initiated, prospective, multicenter, randomized controlled trial comparing the safety and efficacy of aspirin cessation or continuation in perioperative period of noncardiac surgery in patients who have undergone PCI with DES for more than 12 months (Figure 1). Key exclusion criteria includes recent acute coronary syndrome (ACS) (within 1 month), severe left ventricular dysfunction (EF ≤ 30%), severe valvular heart disease, emergent operation, or high bleeding risk operation (e.g., intracranial, intraspinal, or retinal surgery). The primary endpoint was a composite of all-cause death, stent thrombosis, MI and stroke from 5 days before to 30 days after surgery. From March 2017 through to March 2024, a total of 900 patients were enrolled. The primary results will become available this year, which is anticipated to provide valuable clinical evidence to determine optimal antiplatelet therapy in patients who underwent PCI with DES before noncardiac surgery. Figure 1. The study design of the ASSURE DES trial Clinical Science Ongoing Trials from Asan Medical Center Saturday, April 27, 11:30 AM ~ 12:40 PM Presentation Room 1, Level 1 Check The Session

April 25, 2024 1391