New challenging cases presented at TCT 2026 and simultaneously published across the JACC family of journals offer insights into key questions and challenging scenarios in interventional cardiology. Read highlights from a selection of cases:

JACC: Cardiovascular Interventions Challenging Cases

Sho Nakao, MD, and colleagues present a first-in-human case showing how imaging through a novel hybrid IVUS/optical frequency domain imaging catheter guided treatment decisions and optimized complex PCI in a 72-year-old man with exertional angina and prior coronary stenting.

Toshiyuki Iwaya, MD, and colleagues describe how multimodality imaging identified a delayed periaortic hematoma as the cause of severe left main coronary compression in a 31-year-old man after aortic valve replacement.

In an additional case, Ibrahim Naoum, MD, and colleagues report that targeted mitral transcatheter edge-to-edge repair (M-TEER) eliminated systolic anterior motion (SAM) and left ventricular outflow tract obstruction in a 57-year-old woman who developed dynamic SAM following mitral valve repair.

JACC: Case Reports Challenging Cases

Delayed-Presenting STEMI
Yanfu Wang, MD, PhD, and colleagues present two cases of delayed-presenting STEMI in which prolonged, targeted sodium nitroprusside infusion through an indwelling microcatheter restored coronary blood flow after refractory coronary no-reflow. Take-Home Message: “Extensive hibernating myocardium may remain dysfunctional after primary PCI in patients with STEMI; targeted and continuous microcirculatory vasodilation can effectively salvage this viable tissue and improve cardiac function. Supported by novel technological advancements, expanding the conventional emergency time window for primary PCI may be clinically justified to optimize myocardial salvage.”

Vascular Plug Device
Vyanne Hei-Tung Chan, MBBS, and colleagues report exactly “How We Did It” when using a vascular plug device as a stabilizing anchor to facilitate controlled coil deployment during coil embolization of a large, high-flow pseudoaneurysm in a 77-year-old woman after TAVR with bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction (BASILICA). Take-Home Message: “During coil embolization of a large, high flow pseudoaneurysm, a vascular plug device can be used as a stabilizing anchor and scaffold to facilitate controlled coil deployment and allow packing of the pseudoaneurysm.”

BA-BISILICA
In another “How We Did It,” Vahe Shahmoradi, MD, and colleagues detail how balloon-augmented bicuspid scallop intentional laceration to induce circularization of the aortic implant (BA-BISILICA) before TAVR facilitated uniform transcatheter heart valve expansion in a 62-year-old man with severe Sievers type I bicuspid aortic stenosis (AS). Take-Home Message: “In Sievers type 1 bicuspid aortic valve anatomy, precise raphe targeting and laceration are critical determinants of BA-BISILICA success. BA-BISILICA may have important implications for transcatheter heart valve durability and hemodynamic performance in patients with Sievers type 1 bicuspid aortic valve anatomy undergoing TAVR.”

Occlusive Multivessel Coronary Vasospasm
Gabriela Barsante Nicolela, MD, and colleagues describe a 63-year-old man with heart failure (HF) with reduced ejection fraction who experienced cardiac arrest and ST-segment elevation due to occlusive multivessel coronary vasospasm, which was identified and reversed with intracoronary nitroglycerin. Take-Home Message:
“Consider occlusive vasospasm in ST-segment elevation with previously nonobstructive coronaries; exclude aortic causes, then use intracoronary nitroglycerin diagnostically and therapeutically.”

Concomitant Transcatheter Aortic and Tricuspid Valve Replacement
Jaiel Niamat, MD, and colleagues present the case of a 65-year-old man with advanced right HF, torrential tricuspid regurgitation and severe AS who underwent concomitant TAVR and transcatheter tricuspid valve replacement (TTVR). Take-Home Message: “Concomitant transcatheter aortic and tricuspid valve replacement in one procedure is feasible and may benefit selected patients. Further research is needed to better identify patients requiring adjunctive TTVR after TAVR and to determine the optimal timing (concomitant vs. staged).”

3D CT Projection of the Occluder Footprint
Moiz Saeed, MD, and colleagues describe how preprocedural 3D CT projection of the occluder footprint helped guide successful transcatheter closure in an 82-year-old woman with enlarging ascending aortic pseudoaneurysm near the right coronary ostium. Take-Home Message: “CT sizing defines the pseudoaneurysm neck but not where the expanded retention disc will sit, which is the critical relationship when the neck lies near a coronary ostium. Projecting the known disc dimensions onto the CT reconstruction predicts that footprint before intervention but remains an approximation and does not replace prophylactic coronary protection or confirmation before device release.”

Staged Transcatheter Strategy
In an additional case report, Haibin Jiang, MD, and colleagues report that a 75-year-old man with a postinfarction ventricular septal pseudoaneurysm after PCI was successfully treated with a staged transcatheter strategy that occluded the larger outlet first, followed by the inlet five months later. Take-Home Message: “Early recognition is critical: postinfarction ventricular septal dissection should be suspected in patients with recurrent HF or new murmurs after acute myocardial infarction, even in the absence of an acute shunt; transthoracic echocardiography and CT are essential for diagnosis. Staged intervention can be effective: in complex ventricular septal pseudoaneurysm with unsuitable anatomy for single-device closure, a staged percutaneous strategy – outlet occlusion first, followed by a delayed inlet closure – can achieve progressive hemodynamic improvement and favorable long-term outcomes.”

Calcified Left Main PCI
Estêvão Magalhães Pardi, et al., describe an 82-year-old woman with prior aortic valve replacement, occluded bypass grafts, and left ventricular ejection fraction 41% underwent PCI for a severely calcified distal left main bifurcation (SYNTAX score I 45). Take-Home Message: “In patients with limited contractile reserve, stable arterial pressure may mask declining cardiac output during high-risk coronary intervention.”

2D/3D ICE Guidance
Karl Abou Zeid, et al., describe a 69-year-old man with severe degenerative mitral regurgitation from a medial P3 flail and prior esophagectomy underwent M-TEER exclusively under 2D/3D intracardiac echocardiography (ICE) guidance. Take-Home Message: “Comprehensive 2D and 3D ICE can enable safe and effective M-TEER of challenging A3-P3 pathology when transesophageal echocardiography is contraindicated or not feasible.”

Obstructive Mechanical Aortic Valve Thrombosis
Ana Paula Tagliari, MD, PhD, FACC, and colleagues describe how percutaneous mechanical aspiration combined with controlled catheter-disc interaction restored prosthetic disc mobility in a 76-year-old man with obstructive mechanical aortic valve thrombosis. Take-Home Message: “Mechanical prosthetic valve thrombosis presents a major therapeutic challenge when fibrinolysis is contraindicated and redo surgery carries prohibitive risk. This case demonstrates the feasibility of large-bore percutaneous mechanical aspiration under continuous imaging guidance and cerebral embolic protection, suggesting a potential bailout strategy for carefully selected patients.”

Explore more simultaneously published research through JACC Journals’ TCT 2026 Coverage, and visit ACC’s TCT Meeting Coverage for additional studies, clinical insights and news from the meeting.

Clinical Topics: Cardiac Surgery, Cardiovascular Care Team, Congenital Heart Disease and Pediatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Stable Ischemic Heart Disease, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and CHD and Pediatrics, Cardiac Surgery and Heart Failure, Cardiac Surgery and SIHD, Cardiac Surgery and VHD, Congenital Heart Disease, CHD and Pediatrics and Imaging, CHD and Pediatrics and Interventions, CHD and Pediatrics and Prevention, Acute Heart Failure, Interventions and Imaging, Interventions and Structural Heart Disease, Interventions and Vascular Medicine, Echocardiography/Ultrasound, Chronic Angina

Keywords: Transcatheter Cardiovascular Therapeutics, TCT26, Aortic Valve, Arterial Pressure, Bicuspid Aortic Valve Disease, Mitral Valve, Percutaneous Coronary Intervention, ST Elevation Myocardial Infarction, Transcatheter Aortic Valve Replacement, Tricuspid Valve, Ventricular Function, Left, Ventricular Outflow Obstruction, Echocardiography, Aortic Valve Stenosis, Heart Failure