The latest innovations and technologies were on display in the ACC.23/WCC Expo, with more than 280 participating industry partners.

Let the clinical games begin! The new March Matchup venue provided a unique opportunity for interactive, fun and maybe a little competitive learning.

Virtual reality was featured in ACC's new Health Equity Hub, offering an inside look at a real patient case.

Key Takeaways: Structural Heart and Revascularization Science

Science presented during ACC.23/WCC provides new insights and guidance in the structural heart and interventional arenas, including the use of transcatheter edge-to-edge repair (TEER) in the settings of tricuspid regurgitation (TR) and mitral regurgitation (MR); immediate complete revascularization of an acute coronary syndrome (ACS); and intravascular imaging for guiding PCI. A look at longer term outcomes in both arenas come from the COAPT and EVOLUT Low Risk studies.

The international TRILUMINATE Pivotal trial of 350 patients with severe TR (mean age 75; 55% women) from 65 centers randomized to TEER or medical therapy showed that TEER was safe and effective and improved quality of life. The primary endpoint, a hierarchical composite of all-cause death, tricuspid valve surgery, hospitalization for heart failure (HF) and improvement in quality of life measured by the Kansas City Cardiomyopathy Questionnaire (KCCQ), favored the TEER group, driven by the 12.3±1.8 points improvement in the KCCQ score vs. 0.6±1.8 points in the control group (p<0.001). At 30 days, 87% vs. 4.8% of the TEER and control groups had less than moderate TR; 98.3% of TEER patients were free of major adverse events.

"Patients with [TR], when treated with [TEER] with the TriClip device, experienced significant improvements in quality of life," said Paul Sorajja, MD, FACC, lead author of the study, which was simultaneously published in NEJM. "In a patient population with a high symptom burden, this is a meaningful benefit."

In the largest study to examine outcomes of transcatheter mitral valve repair outside of the clinical trial setting, Raj R. Makkar, MD, FACC, et al., analyzed STS/ACC TVT Registry data from 19,088 patients (average age 82, 49% women, median risk of death within 30 days of surgery 4.6%) who underwent TEER with the MitraClip device for moderate to severe isolated degenerative MR from Jan. 1, 2014 to June 30, 2022. Patients who had undergone surgery or a previous transcatheter procedure to repair a mitral valve were excluded, along with those with secondary MR.

The study's primary endpoint, MR success defined as moderate or better residual MR without severe stenosis, was achieved in 88.9% of patients. Optimal MR success (MR of mild or less severity without severe stenosis) was observed in 64.2% of patients.

Looking at clinical outcomes at one year in patients who had successful vs. unsuccessful procedures, respectively, mortality was 14.0% vs. 26.7%; HF readmission 8.4% vs. 16.9%; and mitral valve reintervention 2.1% vs. 13.5%. In patients with a successful procedure, one-year mortality was lower for those with mild or less residual MR vs. moderate MR (12.3% vs. 18%).

"We found that over the eight-year period that we studied, the procedural success rate increased from 81.5% in 2014 to 92.2% in 2022," said Makkar. "Optimal success – a reduction in residual mitral leakage to mild or less – was attained in 64% of patients overall, but that increased from 44.6% in 2014 to 71.7% in 2022."

The five-year data from the COAPT trial showed that TEER with the MitraClip device on top of maximally tolerated guideline-directed medical therapy (GDMT) for HF vs. GDMT alone for patients with severe secondary MR (grade 3-4+) was safe, cut the rate of hospitalizations for HF and reduced all-cause death.

The primary effectiveness endpoint was all hospitalization for HF within two years. After five years, among the 614 randomized patients (average age 72, 36% women), death or hospitalization for HF occurred in 73.6% and 91.5% of the TEER and control groups. The annualized rate of hospitalization for HF through five years was 33.1% and 57.2% for the TEER and control groups. Overall, TEER was associated with a 28% risk reduction in all-cause mortality.

"MitraClip made a profound difference for patients with [HF] and severe MR. Based on these findings, appropriate patients should be treated with MitraClip as early as possible," said Gregg W. Stone, MD, FACC, who presented the findings. However, he noted that even after successful MitraClip, nearly three in four patients died or were hospitalized, because the underlying left ventricular dysfunction is not treated. "We need to develop better therapies for advanced [HF] if the prognosis of this high-risk patient population is to be further improved."

The UK MINI MITRAL trial showed that in 330 patients (average age 67, 30% women) with severe degenerative MR treated at 10 centers in the U.K. and randomized to mitral valve repair by either sternotomy or mini-thoracotomy there was no between-group difference for the primary outcome of change in physical function and ability to return to work at 12 weeks.

"The study has also answered two key questions about the mini-thoracotomy approach – the valve repair rate and the quality and durability of valve repair performed using this approach," said Enoch Akowuah, MD. "Valve repair rates were excellent [at 96%] and similar with those obtained with sternotomy. Moreover, at one year after surgery more than 92% of patients in both groups had no or mild valve leakage."

The three-year outcomes from the EVOLUT Low Risk trial, presented by John K. Forrest, MD, FACC, found that rates of the primary outcome of death and disabling stroke were lower among patients with severe symptomatic aortic stenosis and a low surgical risk treated with transcatheter vs. surgical aortic valve replacement (7.4% TAVR vs. 10.4% SAVR; HR, 0.70; p=0.051). The difference between treatment arms remained broadly consistent over time: –1.8% at year one; –2.0% at year two; –2.9% at year three.

On the interventional front, in patients with multivessel disease presenting with a STEMI or NSTEMI ACS, immediate complete revascularization was noninferior to delayed complete revascularization for the composite primary outcome (all-cause mortality, myocardial infarction [MI], unplanned ischemia-driven revascularization or cerebrovascular events at one year) in the BIOVASC trial.

Among 1,506 patients at one year, a primary endpoint event occurred in 7.6% vs. 9.4% of patients in the immediate vs. delayed groups (HR, 0.78; p for noninferiority=0.0011). No difference was seen for all-cause death. In the delayed group vs. the immediate group, more patients had a second MI (4.5% vs. 1.9%; HR, 0.41; p=0.0045) and more unplanned ischemia-driven revascularization (6.7% vs. 4.2%).

The RENOVATE-COMPLEX-PCI trial found that PCI guided by intravascular imaging vs. angiography in 1,639 patients in South Korea with complex coronary artery disease was associated with a lower risk of the primary outcome of cardiac death, target vessel MI or target vessel revascularization.

With a median follow-up of 2.1 years, the primary endpoint was observed in 7.7% and 12.3% of the intravascular imaging and angiography groups (HR, 0.64; p=0.008). Cardiac death occurred in 1.7% and 3.8% of the groups; target vessel MI in 3.7% and 5.6%; and repeat revascularization in 6.3% and 7.1%.

"The results of our trial may lead to an increase in the use of intravascular imaging – and, in turn, an improvement in clinical outcomes – among patients with complex coronary blockages who are undergoing stenting," said Joo-Yong Hahn, MD, PhD, who presented the trial.