Evan Shlofmitz

Ten major RCTs involving >16,000 patients have evaluated imaging-guided versus angiography-guided PCI over the past decade. Most demonstrated clinical benefit, although some reported neutral outcomes, highlighting the importance of patient selection, lesion complexity, and procedural optimization. Clinical benefit likely depends on a comprehensive imaging-guided strategy, including procedural planning, real-time decision-making, post-stenting assessment, and correction of suboptimal results. #TCT2026

This year, TCT is stopping in San Diego (and I’ll have to take three flights to get there), and the late-breaking lineup is quite interesting. Here are my favourites, both journalistically and from an interventional cardiology perspective: 1/ P4, a trial of CCTA-guided vs IVUS-guided PCI. We published the design paper in EuroIntervention. Check it out: eurointervention.pcronline.c… 2/ TRANSFORM II, or DCB strategy vs DES, Act III. With REC-CAGEFREE I coming out negative and SELUTION DeNovo being so-so, we really needed a tiebreaker. And here it is. 3/ HD-PCI, a randomized trial of higher vs lower-dose heparin for PCI. I like trials that answer practical, “in or out” questions. I also have to discuss this one right after the presentation, so I’m studying it carefully. 4/ PROGRESS: TAVR or clinical surveillance for moderate aortic stenosis. I still haven’t quite figured out the ambition and magnitude of these TAVR trials in moderate AS. The first one, TAVR UNLOAD, didn’t leave much of a mark. We don’t know when EXPAND TAVR II will be presented, but I suspect it’ll be soon. And then there’s PROGRESS, the largest of them all in terms of patient numbers. By the way, ClinicalTrials.gov says follow-up will end in 2037. As we say back home, campa cavallo. 5/ SIMPLAAFY, antithrombotic monotherapy after left atrial appendage occlusion. I like this trial if only for its name, and I can’t wait to hear how people pronounce it. More importantly, it could give DAPT a serious shove out the door, since it seems to be the main burden holding back LAAO at the moment. 6/ PIONEER IV, angiography-derived FFR vs usual care for lesion selection and optimization in all-comers PCI. Another QFR trial occupying an intermediate position on the physiology spectrum between FAVOR III Europe and FAVOR III China. 7/ VERONICA, where researchers are trying to demonstrate the usefulness of platelet-function testing to identify patients with excessive platelet inhibition (usually, it’s the opposite) and see whether a de-escalation strategy could reduce the combined risk of ischemic and bleeding events.