As TCT 2025 kicks off in San Francisco, key research from the conference will be simultaneously published across JACC Journals – including JACC, JACC: Cardiovascular Interventions, JACC: Case Reports, and JACC: Advances. The following are some highlights from the abstracts:
FIRE: Complete Revascularization Effective Across Spectrum of Kidney Function
Physiology-guided complete revascularization was effective regardless of renal function in patients with a myocardial infarction (MI) and multivessel disease, based on findings from a prespecified analysis of the multicenter, investigator-initiated FIRE trial. The 1,445 patients were 75 years and older and randomized to physiology-guided complete revascularization or culprit-only revascularization and stratified by estimated glomerular filtration rate (eGFR) <60 mL/min/1.73m2 (n=662) or ≥60 mL/min/1.73m2 (n=783). More patients in the eGFR <60 group, vs. >60, experienced a primary endpoint, a composite of death, MI, stroke and ischemia-driven revascularization at three years (34% vs. 20%). A lower eGFR was independently associated with a higher risk of the primary endpoint (adjusted hazard rate [HR], 1.42; p<0.001). Complete revascularization reduced the primary endpoint in both eGFR groups (HR, 0.68 and 0.80 respectively). “Despite the traditional hesitancy to pursue complete revascularization in [chronic kidney disease] patients due to concerns about procedural risk or contrast nephropathy, our data supports its use even in this high-risk group,” write study authors Anna Cantone, MD, et al. In an accompanying editorial comment, Hitinder S. Gurm, MD, FACC, and David E. Hamilton, MD, suggest that “the time has come to abandon therapeutic nihilism based on renal function alone.”
EMERGE LAA: Intracardiac vs. Transesophageal Echocardiography-Guided Closure
Results from the EMERGE LAA post approval study showed that the rates of procedural success and left atrial appendage (LAA) closure were high whether the Amulet includer implantation was guided by intracardiac echocardiography (ICE) or transesophageal echocardiography (TEE). In this analysis of 11,848 patients from ACC’s LAAO Registry who had an Amulet includer implanted between August 2021 and December 2023, the procedure was guided by ICE in 433 patients, TEE in 9,793 and both in 1,622. Procedural success was 95%, 96% and 96%, respectively (p=0.324). At 45 days, there was >95% at clinically relevant closure in all three groups and the rates across groups were similar for the safety composite endpoint and 45-day major adverse event composite outcome. Both the ICE and ICE+TEE arms had a longer procedural time (104.8 min and 98.8 min vs. 82 min with TEE), but study authors Mohamad Alkhouli, MD, FACC, et al., note this may reflect a learning curve because more experience with ICE led to “increased implant success, decreased procedural times and lower adverse events rates.”
TTVR Using EVOQUE Post T-TEER
In a case series of patients with residual severe tricuspid regurgitation (TR) after tricuspid transcatheter edge-to-edge repair (T-TEER), transcatheter tricuspid valve replacement (TTVR) was successful in 15 of the 16 patients. John T. Saxon, MD, FACC, et al., also reported that 15 were alive at 30 days, 13 improved to NYHA class I/II (p<0.001) and TR severity improved to none or mild in 93% (p<0.001). The median age of the patients was 75 years and 69% were women, and the median STS PROM was 8.3% and 81% were in NYHA class III/IV heart failure. Of note, eight of the patients also underwent electrosurgical leaflet modification with a novel technique (clip liberalization to facilitate TTVR [CLEFT]) immediately before TTVR. The authors write that, “our conceptual framework for selection of CLEFT versus stand-alone EVOQUE TTVR without leaflet modification facilitated a high percentage of procedural success with limited residual [paravalvular leak], suggesting this is a promising approach.” “These are excellent results from this pioneering experience in a range of anatomies,” write Jaffar M. Khan, MD, PhD, and Harminder S. Gill, MD, in an accompanying editorial comment. “[The authors] demonstrate TTVR after failed TEER is feasible, and reasonably safe and effective.”
EuroTR Registry: T-TEER in Patients With CIEDs
In a study leveraging data from the EuroTR Registry, investigators Jennifer von Stein, MD, et al., found that T-TEER was safe and effective in 3,025 patients, 851 of whom had transvalvular cardiac implantable electronic devices (CIEDs) – with TR ≤1+ and TR ≤2+ being achieved in 40% and 80% of patients at discharge, respectively, and in 29% and 69% of patients at a median follow-up of 269 days. Between 385 matching pairs of CIED and non-CIED patients, residual TR, functional status and two-year heart failure hospitalization-free survival were comparable. CIED presence was not significantly associated with more adverse outcomes (HR, 1.31; p=0.064) but was not associated with residual TR >2+ (odds ratio, 0.98; p=0.915), which was found to be more prognostically relevant. “Given the comparable safety and efficacy outcomes, patients with CIEDs should continue to be included in future trials to refine selection criteria and validate long-term outcomes in this growing population,” write the investigators.
TRANSPARENT Registry: M-TEER Feasible in Patients With Obstructive HCM, SAM-Related MR
The retrospective, international, multicenter TRANSPARENT Registry study found transcatheter mitral edge-to-edge repair (M-TEER) was safe and effective in 35 patients at high surgical risk with obstructive hypertrophic cardiomyopathy (HCM), left ventricle outflow tract (LVOT) obstruction and moderate-to-severe systolic anterior motion (SAM)-related mitral regurgitation (MR). Mitral Valve Academic Research Consortium-defined technical, 30-day device and procedural success was achieved in 94%, 91% and 88% of cases, respectively, with MR <2 achieved in 97% of patients. Additionally, LVOT gradient decreased from 62.0 mm Hg to 16.0 mm Hg and persisted during a median follow-up of 523 days. The proportion of patients in NYHA class I/II increased from 31% to 88%, and the composite outcome of all-cause death, admission for acute decompensated heart failure, M-TEER re-do or surgical valve replacement occurred in 26% of cases, primarily driven by acute decompensated heart failure. Of interest, “no patients in our cohort received mavacamten or aficamten,” investigators Luca Testa, MD, PhD, et al. note. “These findings suggest that, in the future, combining myosin inhibitors with M-TEER could further enhance both hemodynamic and clinical outcomes in this challenging patient population.”
Ischemic Left Ventricular Dysfunction Focus of Review
A review by Matthew Ryan, PhD, et al., dives into the epidemiology, pathophysiology and treatment strategies for ischemic left ventricular dysfunction (iLVD). The authors examine current evidence surrounding revascularization in iLVD and provide a detailed framework to select between CABG and PCI in different patient populations and planning and performing PCI. “The choice of PCI or CABG should be informed by patient factors and choices, rather than institutional preference,” write Ryan, et al. “Delivering safe and effective revascularization requires meticulous patient selection, procedure planning, and significant expertise within the catheter lab team and wider healthcare institution.” They emphasize the importance of not only shared decision-making, but teamwork, communication and leadership among the entire cardiovascular care team. They also discuss current gaps in the evidence, ongoing controversies in the field and future directions to better study PCI in a complex, high-risk patient population.
Click here to see all the articles simultaneously published in the JACC Journals.
Keywords:
Transcatheter Cardiovascular Therapeutics, TCT25
