The Transcatheter Cardiovascular Therapeutics (TCT) 2025 meeting in San Francisco delivered one of the most energizing late-breaking clinical trial lineups in recent memory. From coronary interventions to valve therapies and pulmonary embolism (PE) care, this year's data painted a vision of precision, restraint and personalization in interventional cardiology.

Coronary Intervention: Less Metal, More Medicine

Drug-Coated Balloons Move to Center Stage

Among the most talked-about sessions was the rise of sirolimus-eluting drug-coated balloons (DCBs). In the SELUTION DeNovo trial, more than 3,000 patients were randomized to a DCB-first approach vs. conventional drug-eluting stent (DES) implantation for de novo lesions. At one year, the DCB strategy proved noninferior to DES for target-vessel failure, signaling a genuine paradigm shift.

Clinically, this means operators may increasingly favor a "leave-nothing-behind" approach – particularly for small vessels, bifurcations and side branches – where stent-related late events can be avoided. Rather than a full-scale stent replacement, the field is moving toward selective use based on lesion morphology and vessel size.

In parallel, SELUTION4ISR confirmed that sirolimus DCBs matched repeat DES implantation for in-stent restenosis. The ability to treat restenosis without adding more metal layers reinforces the appeal of DCBs as a clean, vessel-preserving therapy.

Calcified Lesions: Simpler Tools, Similar Outcomes

The VICTORY trial compared super-high-pressure noncompliant balloons to intravascular lithotripsy (IVL) in heavily calcified lesions. The results showed noninferiority for stent expansion and procedural success.

The takeaway is pragmatic: IVL remains invaluable for extreme calcium, but well-executed high-pressure ballooning can achieve excellent outcomes at lower cost and with broader availability. Institutions facing budget constraints may adopt a stepwise strategy - balloon preparation first, IVL reserved for resistant lesions.

Post-CABG PCI: Conventional Wisdom Challenged

For decades, guidelines have favored native-vessel PCI over graft intervention when bypasses fail. The PROCTOR trial defied this dogma. Patients treated with saphenous vein graft (SVG) PCI had fewer major adverse cardiac events than those undergoing native-vessel PCI, driven by less procedural myocardial infarction (MI) and lower repeat revascularization rates. If durability holds up, this will prompt guideline reevaluation and more nuanced, anatomy-driven decisions within the Heart Team framework.

Physiology-Guided STEMI Care: A Reality Check

The iMODERN trial tested immediate, iFR-guided multivessel revascularization in STEMI against deferred, CMR-guided staged care. The study found no superiority for the immediate strategy. The implication: for stable patients, deferral with functional imaging remains a sound, patient-centric path. It reinforces that completeness of revascularization matters – but timing and context matter just as much.

Microvascular Obstruction: The Search Continues

STRIVE explored intracoronary low-dose alteplase during primary PCI for large-territory STEMI. Disappointingly, there was no reduction in microvascular obstruction or improvement in outcomes – and a hint of higher arrhythmia risk. The message: fibrinolytics are not the answer, and new anti-microvascular injury approaches are still needed.

MINOCA: The Power of a Precise Diagnosis

The PROMISE trial, the first randomized study in myocardial infarction with nonobstructive coronary arteries (MINOCA), showed that an etiology-guided strategy after comprehensive imaging improved angina and diagnostic accuracy. The results validate systematic work-ups – combining CMR, intracoronary imaging and vasoreactivity testing – before empiric therapy. MINOCA management must be mechanism-based, not one-size-fits-all.

Structural Heart Disease: Reassurance and Expansion

TAVR Durability Reaches the Seven-Year Mark

The much-anticipated seven-year outcomes from PARTNER 3 finally addressed long-term durability concerns. In low-risk aortic stenosis, transcatheter and surgical valve replacement showed similar survival, stroke and rehospitalization rates, as well as comparable valve durability.

This provides critical reassurance that TAVR can serve not only as a bridge for the elderly but also as a legitimate long-term solution for younger, low-risk patients – provided lifetime management and potential future interventions are carefully planned.

TMVR in Severe MAC: A New Lifeline

For patients with severe mitral annular calcification, historically deemed "no-option," the SUMMIT-MAC trial using the Tendyne system demonstrated high procedural success, sustained MR reduction and significant symptomatic improvement at one year. Apical access bleeding remains the main procedural challenge, but this marks a meaningful therapeutic advance for a group previously relegated to palliation.

Tricuspid Therapies: Gaining Confidence

Expanded data from TEER and replacement systems continue to affirm safety, durable symptom improvement and growing operator experience. Patient selection remains key: right-ventricular function, pulmonary pressures and annular geometry determine success. The once-ignored tricuspid valve is now firmly in the spotlight, with technology and evidence rapidly catching up.

Vascular and PE Interventions

STORM-PE: Mechanical Intervention Arrives

Perhaps the most practice-changing vascular trial was STORM-PE, comparing catheter thrombectomy with anticoagulation alone in intermediate-risk PE. Thrombectomy significantly reduced clinical deterioration and improved right ventricular function without excess bleeding.

This establishes a new therapeutic benchmark: for selected patients, removing clot matters. Hospitals are now expected to develop 24/7 Pulmonary Embolism Response Teams (PERTs) and ready access to thrombectomy devices. For interventionalists, PE care is becoming an integral service line, not a niche procedure.

Disruptive Technologies and Imaging Innovation

Bioadaptors: The Next Evolution Beyond DES

The INFINITY-SWEDEHEART trial introduced the DynamX Bioadaptor – an implant that functions like a DES initially but gradually unlocks as the polymer resorbs, allowing the vessel to regain natural motion. From six to 24 months, target-lesion failure rates dropped nearly by half compared with conventional DES, especially in acute coronary syndrome.

This "adaptive scaffolding" approach could redefine durability and late-event profiles, offering freedom from the permanent metallic cage while maintaining early antiproliferative benefit.

AI-Guided Plaque Imaging: Predicting the Future

Advances in quantitative coronary CT angiography using artificial intelligence (AI) showcased the power of imaging-based prevention. By quantifying noncalcified and high-risk plaque, AI-QCT can reclassify risk beyond luminal stenosis. In practical terms, clinicians will be able to identify patients with dangerous plaque biology earlier and intervene medically before events occur.

The broader theme emerging from TCT 2025 is not just treating obstruction but predicting and preventing it.

Clinical Topics: Invasive Cardiovascular Angiography and Intervention

Keywords: Cardiology Magazine, ACC Publications, Drug-Eluting Stents, Interventional Cardiology, TCT25, Transcatheter Cardiovascular Therapeutics