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AP VALVES & SH 2024

TAVR in Asia: Optimal TAVR Choice for Asian Patients with Small Annulus, Vessels, and Body Size

At the AP VALVES & SH 2024 conference, Duk-Woo Park, MD, PhD (Asan Medical Center, Korea), highlighted critical considerations for Transcatheter Aortic Valve Replacement (TAVR) in Asian populations, particularly focusing on patients with smaller annuli, vessels, and body sizes. As TAVR becomes increasingly adopted across Asia, the unique anatomical challenges posed by these smaller dimensions demand careful selection of prosthetic valves to optimize patient outcomes. One of the key concerns discussed was the prevalence of small aortic annuli in the Asian population, which occurs in approximately 40% of cases. This anatomical feature is associated with a higher risk of prosthesis-patient mismatch (PPM), where the implanted valve is too small relative to the patient’s body size. This mismatch can lead to increased mechanical stress on the valve leaflets, accelerating structural valve degeneration and reducing long-term durability—a concern particularly pertinent given the growing emphasis on valve longevity in the region. The session also underscored the racial disparities in TAVR outcomes, with Asian patients showing a higher incidence of severe PPM compared to their Western counterparts. This difference emphasizes the need for tailored approaches when treating Asian patients. He noted that while newer generation valves have improved hemodynamic performance, ensuring an optimal fit remains challenging, particularly for high-risk patients and younger, more active individuals. Further insights were provided from the SMART trial, which compared self-expanding valves (SEV) and balloon-expandable valves (BEV) in patients with small aortic annuli. The trial, one of the largest and most rigorous to date, revealed that SEVs offered superior valve performance, including a 32.2% lower incidence of bioprosthetic valve dysfunction and a 5.3% reduction in severe PPM. These findings suggest that SEVs may be particularly advantageous for Asian patients, though the direct applicability of the trial’s results to this population remains a subject of ongoing debate. In conclusion, while advancements in TAVR technology are promising, the conference highlighted the necessity of further research and validation to ensure these innovations translate into improved outcomes for Asian patients with small annuli and other unique anatomical features. Keynote Lectures on TAVR 2024 Friday, August 09, 1:00 PM ~ 2:00 PM Main Arena, Vista Hall 1, B2 Check The Session

September 06, 2024 2989

AP VALVES & SH 2024

15 Years' Journey of AMC TAVR

At the AP VALVE & SH 2024 conference, Seung-Jung Park, MD, PhD (Asan Medical Center, Korea), marked the 15th year anniversary of pioneering Transcatheter Aortic Valve Replacement (TAVR) at AMC. Over this period, AMC has evolved from its initial procedures to becoming a leader in the field, consistently improving outcomes and expanding the range of patients who can benefit from TAVR. Evolution of TAVR Guidelines and Clinical Practice Since the pivotal 2010 PARTNER IB trial, TAVR has gained acceptance as a preferred treatment for patients with severe aortic stenosis, particularly those at high surgical risk. Recent trials, including the SMART trial, have further demonstrated TAVR's benefits in younger, lower-risk populations. The meta-analysis of low-risk TAVR trials involving over 2,000 patients shows that TAVR offers superior one-year mortality rates and cardiovascular outcomes compared to Surgical Aortic Valve Replacement (SAVR). The 2020 ACC/AHA guidelines recommend TAVR as the first-line treatment for patients over 65 years old. While the ESC guidelines suggest TAVR primarily for patients over 75, with individualized assessments for those younger. However, real-world data shows a trend toward using TAVR in younger patients, with 78% of patients under 65 receiving TAVR in 2021-2022. This shift reflects a growing preference for tissue valves over mechanical ones, driven by TAVR's minimally invasive nature and favorable outcomes. AMC's TAVR Success: The Role of Minimalist Approaches and CT Algorithms AMC has now performed over 2,000 TAVR procedures, with a current rate of 300 cases annually. The center boasts a procedural success rate of 99.7%, low complication rates, and excellent one-year outcomes, including an all-cause mortality rate of 7.2% and a disabling stroke rate of less than 1%. This success is attributed to AMC’s heart team collaboration, a minimalist approach to anesthesia and patient care, and the precision of the AMC CT algorithm for device selection. The AMC CT algorithm is a cornerstone of this success, allowing for meticulous pre-TAVR planning. By analyzing factors such as vascular access, aortic annulus size, calcium distribution, and coronary height, the team at AMC ensures optimal device sizing and placement. This approach has led to low rates of paravalvular leak (PVL) and permanent pacemaker implantation, particularly with the use of balloon-expandable devices, which are preferred for their strong radial force and predictable outcomes. AMC continues to adapt its techniques to address complex cases, such as those involving bicuspid aortic valve stenosis, which typically involves higher calcium burdens and more challenging anatomies. In these cases, AMC has successfully applied its refined approaches, resulting in procedural outcomes comparable to those in tricuspid valve cases. In-depth Analysis of the SMART Trial and its Implications on TAVR Practices During the discussion of the SMART trial, particular focus was given to the management of patients with small aortic annuli (less than 430 mm²). The trial compared outcomes between self-expanding and balloon-expandable valves, with the latter using primarily 23mm devices. While both groups had similar clinical profiles, notable differences in procedural characteristics emerged. However, the device success rate was slightly lower compared to self-expanding valves. At AMC, where approximately 40% of patients fit the SMART trial criteria, data showed a high procedural success rate and a significantly lower incidence of paravalvular leak (PVL) compared to the SMART trial. This discrepancy highlights the importance of meticulous device selection and sizing, particularly in patients with small annuli. AMC’s approach, which carefully considers factors like annulus size and calcium load, has proven effective in optimizing outcomes. The differences between AMC’s outcomes and those of the SMART trial underscore the critical role of pre-TAVR planning using CT analysis. The SMART trial's use of relatively undersized devices without adequate consideration of calcium levels likely contributed to higher PVL rates. In contrast, AMC’s tailored approach, guided by detailed MDCT analysis, emphasizes the importance of precise device sizing to prevent complications. Opening, Live Case & Lecture 1: TAVR Thursday, August 08, 1:00 PM ~ 2:20 PM Main Arena, Vista Hall 1, B2 Check The Session

August 30, 2024 2875

AP VALVES & SH 2024

TAVR for Bicuspid AV: What's Different?

At the AP VALVES & SH 2024 conference, Jung-Min Ahn, MD, PhD (Asan Medical Center, Korea), delivered important findings on the challenges and outcomes of Transcatheter Aortic Valve Replacement (TAVR) in bicuspid aortic valve (BAV) patients. Despite the anatomical complexities of BAV, the data from Asan Medical Center suggest that TAVR can be performed as safely and effectively as in tricuspid aortic valve (TAV) patients, albeit with some unique procedural considerations. Between 2016 and 2023, Asan Medical Center conducted TAVR on approximately 1,000 patients using the Sapien 3 valve system, with 124 of these patients having BAV (Figure 1). They found that BAV patients were generally younger (mean age 77), predominantly male, and had fewer comorbidities compared to those with TAV. Echocardiographic findings indicated more severe aortic valve stenosis in BAV patients, with higher transaortic pressure gradients and more significant calcification, as evidenced by higher calcium volumes (Figure 2). Figure 1 Figure 2 Procedurally, BAV cases required larger transcatheter heart valves (THVs) and more frequent pre- and post-dilation. Notably, in BAV patients with heavy calcification, the strategy leaned toward less valve oversizing to reduce procedural risks (Figure 3). While the rates of pacemaker implantation and paravalvular leak were slightly higher in BAV patients, these differences were not statistically significant. Long-term outcomes showed no significant differences in mortality or stroke rates between BAV and TAV patients up to two years after the procedure (Figure 4, 5). Figure 3 Figure 4 Figure 5 He emphasized the need for developing specific criteria, similar to the Echo-Score used in rheumatic mitral stenosis, to better identify BAV patients who are ideal candidates for TAVR. This could further enhance procedural success and patient outcomes in this complex patient group. Live Case & Lecture 2: Bicuspid, Mitral TEER Thursday, August 08, 2:30 PM ~ 4:10 PM Main Arena, Vista Hall 1, B2 Check The Session

August 30, 2024 2358

TCTAP 2024

FFR and iFR: Where Do We Stand Today?

Reassessment of Coronary Artery Disease Diagnostics: FFR Reigns Supreme Nico Pijls, MD Catharina Hospital, Netherlands In the evolving landscape of cardiology, the debate over the most reliable method for assessing coronary artery disease has reached a crucial juncture. Fractional Flow Reserve (FFR) and Instantaneous Wave-free Ratio (iFR) have both been subjects of intense scrutiny and discussion. However, recent insights, especially new recommendations from leading cardiology journals and associations, are reaffirming FFR as the gold standard for assessing coronary artery disease. Understanding FFR and iFR FFR is an index that measures the maximum achievable blood flow in the presence of a coronary stenosis compared to normal maximum flow. The underlying principles of FFR are rooted in sound physiology. It evaluates the functional capacity of a patient's heart under maximum vasodilation, correlating to exercise tolerance. This method has significantly influenced decision-making in catheterization labs, aiding in precise revascularization strategies and improving patient outcomes. However, FFR measurement necessitates a pharmacological hyperemic stimulus, typically involving adenosine or ATP infusion. Although these agents have transient side effects, the benefits of accurate measurement outweigh the minor inconveniences. In contrast, iFR emerged as a simpler alternative to FFR. Proposed by Davies et al., iFR measures the resting Pd/Pa ratio during a specific part of diastole, eliminating the need for a hyperemic stimulus. Initial enthusiasm for iFR was bolstered by two large randomized controlled trials (DEFINE-FLAIR and SWEDE-HEART), which suggested non-inferiority of iFR compared to FFR. Critical Analysis of iFR Despite the initial optimism, several concerns about iFR have come to light. The concept of a “wave-free period” during diastole lacks a solid physiological basis, and predicting hyperemic gradients from resting gradients has proven unreliable. Furthermore, serious design and interpretation issues in the DEFINE-FLAIR and SWEDE-HEART studies have raised questions about their validity. Notably, these studies involved low-risk populations, with a significant proportion of patients not undergoing PCI and many stents placed without physiological measurements. Biases in the study designs were particularly problematic. For example, almost 50% of stents were placed based on visual lesion severity rather than physiological measurement. Many false-negative iFR results were excluded from the analysis, skewing the data to appear more favorable. This bias went largely unrecognized by investigators, leading journals, and guideline committees. Long-term follow-ups revealed troubling outcomes. Mortality rates in the iFR-guided groups were significantly higher than those in FFR-guided groups, a disparity that increased over time. These findings have prompted a reassessment of iFR's reliability, especially in high-stakes clinical decisions. New Recommendations In response to these revelations, the Journal of the American College of Cardiology (JACC) and the European Heart Journal (EHJ) now recommend FFR as the preferred method for assessing proximal lesions in large coronary arteries. Upcoming guidelines are expected to reflect this preference, emphasizing FFR-guided revascularization as the standard for intracoronary pressure measurement. The cardiology community's initial enthusiasm for iFR and other non-hyperemic pressure ratios has been tempered by emerging evidence of their limitations. The biases and higher mortality rates observed in key studies underscore the necessity of relying on methods with a robust physiological basis. As such, FFR remains the gold standard, ensuring precise diagnostics and optimal patient outcomes in coronary artery disease management. Hot Topics Coronary Physiology: New Insights Friday, April 26, 3:30 PM ~ 5:44 PM Presentation Room 2, Level 1 Check The Session

June 19, 2024 3272

TCTAP 2024

Who Will Treat the Most Complex Patients? No Success Goes Unpunished.

During TCTAP 2024, live cases, and lecture 6, the discussion revolved around the treatment of the most complex patient cases. Spencer B. King, MD (Emory Healthcare, USA), shared insights into the evolving role of percutaneous coronary intervention (PCI) compared to surgery in such cases. In his introductory remarks, he emphasized the shifting landscape of PCI being increasingly favored over surgery, particularly in treating left main (LM) shaft disease. Significant contributions by Seung-Jung Park, MD (Asan Medical Center, Korea) were highlighted in this paradigm shift. Previously, interventionists would often opt for surgery when confronted with challenging cases. However, He noted a trend toward choosing PCI, citing highly sophisticated PCI skills as a driving factor. An illustrative case discussed was that of an 85-year-old male patient with a history of acute coronary syndrome (ACS), recurrent chest pain, and heart failure (Figure 1). The patient presented with multiple risk factors including diabetes, chronic renal failure, cerebrovascular accident, peripheral artery disease, and severe chronic obstructive pulmonary disease. The electrocardiogram confirmed LM disease consistent with ACS. Figure 1. One most complex patient case Initial coronary angiography revealed LM plus triple-vessel disease with complex lesions, including LM trifurcation disease and heavily calcified, diffuse long left anterior descending artery disease, alongside total occlusion of the proximal right coronary artery. Given the patient's profile, both coronary artery bypass surgery (CABG) and PCI were considered. However, CABG was deemed prohibitive due to technical challenges, and the patient's advanced age and comorbidities. PCI posed its own difficulties, including the complexity of LM trifurcation lesions, the need for debulking procedures such as rotablation, and potential requirement for mechanical circulatory support. Assessing the postoperative outcomes, surgical mortality rates were projected to be high, prompting a thorough evaluation of the risks associated with both procedures. Ultimately, PCI was chosen for this high-risk patient, with successful completion reported. He highlighted the lack of randomized controlled trials focusing on PCI for such complex cases. Instead, he referenced a recent registry study involving over 700 patients who were turned down for surgery and underwent PCI at specialized centers. The study showed that there was no difference in the actual mortality rate compared to the mortality rate predicted by the Society of Thoracic Surgeons score and EuroScore II, and that the symptoms of the patients improved 6 months after PCI compared to the baseline condition (Figure 2). Figure 2. Improvement in patient symptoms 6 months after PCI compared to baseline condition Looking ahead, he emphasized the need for further research to validate these findings and address key questions surrounding the selection of treatment modalities for complex cases. He advocated the establishment of local registries for high-risk patients to inform clinical decision-making. In concluding the lecture, he left a lasting message for interventional cardiologists that no spectacular success will go unpunished and the more tough cases you take, the more you will get, which may be a good thing. As the field continues to evolve, the quest for optimal treatment strategies for the most complex patients remains ongoing. Live Case & Lecture 6: Complex PCI Friday, April 26, 3:30 PM ~ 5:00 PM Main Arena, Level 2 Check The Session

June 19, 2024 2271

TCTAP 2024

Provisional Stenting in Left Main vs. Non-Left Main Complex Bifurcation Stenoses: Is There a Differe...

Scott Harding, MD (Wellington Hospital, New Zealand), was the first presenter in the ‘New concept of Bifurcation PCI’ session, highlighting the unique characteristics of the left main bifurcation compared to other bifurcations (Figure 1). The Left main bifurcation is a larger vessel with crucial branches in almost all cases. Notably, the bifurcation angle (B angle) is generally larger, and there is more calcification and fibrosis, particularly at the circumflex ostium. Additionally, the geometry of the left main bifurcation differs significantly from other bifurcations, such as the left anterior descending (LAD) bifurcation. Figure 1. Unique characteristics of Left main bifurcation Importance of the Circumflex and Myocardial Subtension He stressed the importance of the circumflex artery, which supplies more than 10% of the myocardium in 90% of cases. In contrast, only 20% of the non-left main bifurcations supply a similar amount of myocardium. It was noted that CT estimates might overstate these figures, suggesting that the actual numbers could be lower. He emphasized the critical need to avoid leaving significant disease untreated in the circumflex, citing high event rates over 5 years for patients with low fractional flow reserve (FFR) who did not receive intervention. Clinical Outcomes: Left Main vs. Non-Left Main Bifurcations Drawing from various registries, including the Coronary Bifurcation Stent III Registry from Korea, he illustrated that left main bifurcation interventions typically result in worse outcomes compared to non-left main bifurcations. This discrepancy is likely due to the larger area of jeopardized myocardium in Left main cases. The complexity of the disease also significantly impacts outcomes, underscoring the importance of comprehensive treatment strategies. Optimal Stenting Strategies He discussed findings from several trials, including the DKCRUSH-V and EBC MAIN trials, which suggest that complex Left main bifurcations benefit more from a two-stent strategy than a provisional strategy. The DKCRUSH-V trial showed a significant reduction in target lesion revascularization with a two-stent approach, especially in complex lesions (Figure 2). Conversely, the EBC Main trial found a provisional approach to be non-inferior in less complex diseases. These results highlight the necessity of tailoring stenting strategies to the complexity of the lesion. Figure 2. Benefits of two-stent strategy from DKCRUSH-V trial Unintentional Stent Deformation: Insights from the OCTOBER Trial An important point from his lecture was the issue of unintentional stent deformation, revealed in the OCTOBER trial. The trial found that 9% of cases experienced unintended stent deformation, with this rate increasing to 19% in left main bifurcations. Factors contributing to this complication include guide catheter collision and abluminal wiring, particularly in complex left main procedures (Figure 3). This finding underscores the need for meticulous attention during stent placement. Figure 3. Mechanisms and outcomes of unintentional stent deformation He concluded by reiterating the differences and challenges associated with left main bifurcation interventions. He noted that the worse outcomes often seen in these cases reflect the large amount of jeopardized myocardium. While a provisional stenting strategy can be effective for most non-left main bifurcations, an upfront two-stent strategy is often warranted for complex left main lesions. These decisions should be guided by the specific characteristics and complexity of the disease. TCTAP Workshops New Concept of Bifurcation PCI Thursday, April 25, 4:00 PM ~ 5:40 PM Valve & Endovascular Theater, Level 2 Check The Session

June 19, 2024 2170

TCTAP 2024

Don't Forget About Dual Pathway Inhibition: When DOAC Should NOT Be Standard Treatment

Dominick J. Angiolillo, MD (University of Florida College of Medicine, USA), recently delivered a compelling lecture on the nuances and critical considerations surrounding dual pathway inhibition (DPI). The presentation started by introducing basic concepts of thrombosis formation (Figure 1). In case of an atherosclerotic plaque rupture, two key pathways are activated; the cellular pathway represented by platelets, as well as the plasma component represented by thrombin. The surface of the activated platelets is the main source for generation of thrombin, indicating an interplay between the two mechanisms. Despite efforts to block platelet activation, thrombosis continues to occur, leading to the concept of DPI of both platelets and coagulation. Figure 1. Mechanism of thrombus formation Ischemic events continue to occur even during aspirin monotherapy, and there have been some disappointments with the strategies of using alternative antiplatelet therapies. This led to a question of whether a very low-dose rivaroxaban (2.5 mg bid) in adjunct to aspirin can reduce ischemic events, which was tested in the COMPASS trial (Figure 2). The landmark COMPASS trial examined nearly 30,000 patients to determine the efficacy of adding low-dose rivaroxaban to aspirin therapy. Results from this trial indicated a significant decrease in ischemic events when using the combined DPI strategy versus aspirin alone, reshaping long-term secondary prevention tactics for patients with stable coronary and peripheral artery disease (CAD and PAD). Figure 2. Primary Endpoint of the COMPASS trial Despite these promising outcomes, the inherent risks associated with DPI were also addressed, which is an increased incidence of major bleeding events (Figure 3). This aspect remains a crucial consideration in clinical decision-making, emphasizing the need for careful patient selection based on individual risk profiles. Figure 3. Bleeding Outcomes from the COMPASS trial Studies on intensified antithrombotic therapy for long-term secondary prevention in patients with chronic coronary syndrome were highlighted (Figure 4), and the lecture concluded with a detailed algorithm to aid physicians in selecting the appropriate therapeutic strategy, considering factors such as high-risk features of both bleeding and ischemic events, including multivessel coronary disease, chronic kidney disease, diabetes, recurrent myocardial infarctions, and history of prior ischemic stroke (Figure 5). Figure 4. Studies on intensified antithrombotic therapy for long-term secondary prevention in CCS Figure 5. Algorithm for the choice of antithrombotic therapy in CCS patients Hot Topics All About New Data of Antithrombotics Friday, April 26, 4:40 PM ~ 6:06 PM Presentation Room 1, Level 1 Check The Session

June 19, 2024 2113

TCTAP 2024

Bicuspid TAVR: All the Technical Issues and Data from Asan Medical Center

Jung-Min Ahn, MD, PhD (Asan Medical Center, Korea), presented a comprehensive overview of the technical challenges and clinical outcomes associated with transcatheter aortic valve replacement (TAVR) in patients with bicuspid aortic stenosis (AS) from Asan Medical Center. He highlighted the clinical and anatomical challenges of treating bicuspid AS with TAVR, emphasizing that clinical evidence is still limited. He referenced a large dataset of 12,000 patients, comparing outcomes between bicuspid and tricuspid aortic valve TAVR. The data showed no significant differences in hard endpoints, though bicuspid TAVR was associated with an increased risk of paravalvular leak (PVL) and aortic root injury. One key discussion point was comparing TAVR and surgical aortic valve replacement (SAVR) in bicuspid aortic valve stenosis. While some studies showed no difference in mortality, others suggested numerically higher risk with SAVR, though this was not statistically significant (Figure 1). Device-specific outcomes were also discussed, noting that self-expandable devices had a higher risk of moderate or significant PVL, whereas balloon-expandable devices were associated with a higher risk of annulus rupture and aortic root injury. Figure 1. Comparison of TAVR and SAVR in bicuspid AS He emphasized the importance of calcification in bicuspid valves. These valves often have a higher amount of calcium compared to tricuspid valves, which may lead to higher procedural risks. It was also pointed out that younger patients typically have a higher incidence of bicuspid AS, while it’s not as common in older age groups. The presentation also included data on device sizing. Most bicuspid valves fall into tubular and flare types, which allow for device sizing based on annular size in 90% of cases. He primarily focused on the Sapien 3 device, noting its effectiveness when sized correctly. He stressed the importance of avoiding oversizing in cases of severe calcification to reduce the risk of complications (Figure 2). Figure 2. Importance of avoiding oversizing in cases of severe calcification He concluded that bicuspid AS has distinct clinical and phenotypical characteristics, such as younger patient age, more severe aortic valve calcification, and associated aortopathy. The incidence of paravalvular leak is higher compared to tricuspid aortic valve cohorts undergoing TAVR, and caution should be exercised regarding aortic injury. Despite these challenges, TAVR for bicuspid AS is not associated with an excess risk of mortality and stroke. Sapien 3 implantation in bicuspid aortic valves is comparable to its use in tricuspid valves. Therefore, there is a need to define specific criteria for selecting patients with bicuspid aortic stenosis who can be successfully treated with TAVR, much like the Echo-Score for rheumatic mitral stenosis. Hot Topics TAVR: Future Perspectives Saturday, April 27, 9:00 AM ~ 10:34 AM Valve & Endovascular Theater, Level 2 Check The Session

June 19, 2024 2107

TCTAP 2024

The Series of FAME Studies: A Paradigm Shift in Our Thinking About Interventional Cardiology

William F. Fearon, MD Stanford University, USA Coronary artery disease (CAD) management has significantly evolved over the past decade, largely due to the pivotal findings from the Fractional Flow Reserve versus Angiography for Multivessel Evaluation (FAME) trials. The FAME 1, FAME 2, and FAME 3 studies collectively underscored the transformative role of fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) in optimizing treatment strategies for patients with CAD. Published in 2009, the FAME 1 trial, laid the groundwork for using FFR in guiding PCI. Traditionally, angiography has been the cornerstone for identifying significant coronary stenoses. However, the FAME 1 trial demonstrated that incorporating FFR measurements during PCI significantly improved patient outcomes. The study included 1,005 patients with multivessel CAD. It revealed that FFR-guided PCI, compared to angiography alone, resulted in a lower incidence of major adverse cardiac events (MACE) over 1 year (13.2% vs. 18.3%, p=0.02). FAME 1 established that physiology-guided PCI simplifies the treatment process and enhances the prognostic outcomes for patients undergoing multivessel PCI. The FAME 2 trial, published in 2014, further validated the importance of FFR in patients with stable CAD. De Bruyne and colleagues conducted a study involving 1,220 patients, comparing outcomes between those who received FFR-guided PCI and those managed with medical therapy alone. The results showed patients in the FFR-guided PCI group had a significantly lower rate of the primary composite endpoint of death, myocardial infarction (MI), or urgent revascularization compared to the medical therapy group (4.3% vs. 12.7%, p

June 12, 2024 1243

TCTAP 2024

Calcified Nodules in Complex PCI: Are They All the Same and How Should We Treat?

Akiko Maehara, MD (Cardiovascular Research Foundation, USA), started the lecture with a question, "What kind of calcified plaque should be treated?". The OCT study that was introduced enrolled 272 calcified nodules (CNs) in 230 patients who underwent pre- and post-optical coherence tomography (OCT). Nodules were divided into 2 groups, which were eruptive and non-eruptive CNs. In this study, the prevalence of CN was 5.9% per vessel and 7.3% per patient (Figure 1). Figure 1. OCT trial design Explosive Calcified Nodules (CNs): Predictors of Better Stent Expansion but Worse Post-PCI Outcomes She stated that eruptive CNs are one of the predictors of better stent expansion because of the re-distribution mechanism of plaques. However, eruptive CNs showed a worse post-percutaneous coronary intervention (PCI) outcome in terms of target lesion failure (TLF) compared to non-eruptive CNs (Figure 2). Factors associated with 2-year TLF included eruptive CNs, the circumference of the CN, angle in lesions, and the stent area. The lecture concluded with the following messages, 1) Stent implantation deformed an eruptive CN more than a noneruptive CN 2) Non-eruptive CN, greater CN, greater surrounding calcium, and negative remodeling were associated with poor stent expansion 3) TLR increased at 6 months post-PCI in the eruptive CN group more than non-eruptive CN group 4) An eruptive CN, greater CN, greater hinge motion, and small stent area were associated with a worse 2-year TLF Figure 2. Outcomes pre- and post-PCI in eruptive and non-eruptive CNs Hot Topics All About Tips & Tricks for Complex PCI Saturday, April 27, 9:30 AM ~ 11:10 AM Main Arena, Level 2 Check The Session

June 12, 2024 1137