EuroPCR 2017: New Stents, New Questions for PCI Today and Tomorrow as Angioplasty Turns 40

PARIS, France—This year marks the 40th anniversary of the world’s first angioplasty and EuroPCR 2017, which kicks off Tuesday in Paris, will be pulling out all the stops to mark the occasion. In addition to showcasing a number of trials that speak to just how far the procedure has come—and still has to go—this year’s meeting has dedicated 200 square meters to a special interactive exhibit recounting the history and major milestones.

The “40 Years of Angioplasty” exhibit, which will be located on the third floor of the Palais des Congrès for the duration of the meeting, actually was driven by junior practitioners, course director William Wijns, MD (Lambe Institute for Translational Medicine and Cúram, Galway, Ireland), told TCTMD.

 “We heard from our younger colleagues, ‘We don’t know enough about the past, we would like to learn more about how it was at the start,’” he said.

Late-Breaking Trials and Trial Updates

A total of 10 sessions over the course of the 4-day program have been designated “Hot Lines,” although just two of these will be showcased in the main arena. The eight trials in these two sessions, one Tuesday and one Thursday, are the ones most likely to have an immediate impact on practice, Wijns said.

Tuesday’s batch leads off with TOPIC, a single-center, randomized trial addressing whether changing antiplatelet therapies after 1 month can offset bleeding risk while maintaining anti-ischemic benefit in patients following PCI for ACS. “Early on in these patients, the ischemic risk is high, but later that fades away and the bleeding risk dominates,” Wijns said. In TOPIC, all patients have received aspirin plus ticagrelor (Brilinta; AstraZeneca) or prasugrel (Effient; Eli Lilly) for the first month, then were randomized to continue on that combination or switched to aspirin plus clopidogrel—a far cheaper option. “I think this will be very controversial and heavily discussed,” Wijns predicted.

Also in this first main tent Hot Line is REPRISE III, the first randomized, head-to-head trial comparing two different transcatheter aortic valves, the Lotus (Boston Scientific) and the CoreValve (Medtronic), in high- or extreme-surgical-risk patients. “In addition to the results themselves,” Wijns said, “I think people will be very interested to discuss—are we going to do this all over again, compare devices, like we did with drug-eluting stents?”

Rounding out this first late-breaking session is a pooled, patient-level analysis of the DEFINE-FLAIR and SWEDEHEART trials comparing instantaneous wave-free ratio (iFR) and fractional flow reserve (FFR) in patients with stable angina and ACS. Both trials were previously reported at the American College of Cardiology (ACC) 2017 Scientific Session in March. The fourth trial is DESSOLVE III, a 1,400-patient, randomized comparison of the Xience DES (Abbott Vascular) to the MiSTENT (Stentys), a novel platform that embeds sirolimus microcrystals into the stent wall, allowing for a longer period of drug delivery to the vessel wall. Wijns, who is involved in the trial, said the crystals take approximately 9 months to disintegrate, for lack of a better word, while the bioresorbable polymer coating the stent is gone within 3.

The second main arena Hot Line, on Thursday, includes a cost-efficacy analysis from COMPARE-ACUTE and a detailed look at neurological outcomes in SURTAVI—primary results for both were presented at ACC 2017. The session will also include the AIDA trial, which was recently published in the New England Journal of Medicine and reported by TCTMD at the time, and EuroCTO. Wijns said that the AIDA results, examining outcomes with the Absorb bioresorbable vascular scaffold in the Netherlands, will include new information on implantation technique (the so-called PSP protocol) and how it relates to outcomes. The multicenter EuroCTO trial, meanwhile, tackles another controversial topic: PCI versus optimal medical therapy for the treatment of chronic total coronary occlusions.

Outside these two main sessions are another eight “Hot Line” late-breaking abstract sessions, plenaries, “Focus Practice Sessions,” and other oral abstract presentations spanning everything from STEMI outcomes to advances in left atrial appendage closure to heart failure interventions.

A large part of the program, predictably, is devoted to structural heart disease and includes abstracts on mitral valve disease, bicuspid aortic valve disease, valve leaflet thrombosis/durability, and valve-in-valve procedures, among others.

Bioresorbable scaffolds are the subject of more than a dozen dedicated sessions in this year’s program, highlights being 3-year results from ABSORB China and ABSORB Japan, as well as registry results from countries across Europe. EuroPCR will be issuing an official position on bioresorbable scaffold technology on Tuesday afternoon, Wijns said.

Live cases, one of the chief draws of the meeting, will also have a new look and feel this year, part of the meeting’s “patient-centric” ViTAL LIVE initiative, Wijns said. These sessions will open with a case presentation from the chair—rather than the remote operators as in the past—followed by a 10-minute discussion by the panel and audience as to how they would approach the case, without the participation of the operators. The program will then switch to the case itself where the operators can focus primarily on the procedure, followed by a discussion at the end wherein, time permitting, one or more of the operators will leave the bedside to discuss the case with the panel and chair.

“The idea is to really mimic what happens in real life when you have a difficult case,” Wijns explained, noting that complex case review typically happens with colleagues or the heart team prior to heading to the lab. As such, these changes to the live case format more closely mirror that process, while allowing all the panelists to provide their input without interrupting or delaying the case itself, he said. Most importantly, he noted, it also creates a better barrier between the educational role of the case and the patient undergoing the procedure.

The Youth Vote

A number of other innovations at this year’s EuroPCR also stemmed from input provided by junior cardiologists and trainees who were expressly consulted to help with this year’s program, Wijns said. Among the changes: sessions focused on guideline/practice mismatch, “My Toolbox” sessions where later-career cardiologists detail the technology they depend on in specific clinical scenarios, and “Burning Question” sessions that have no specific agenda. For these 90-minute blocks led by expert operators, Wijns said, attendees were encouraged to submit practical questions in advance: these will be used to prime the discussion, with the audience encouraged to keep the questions and discussion flowing.

Finally, another 90 minutes carved out of the dense program looks more like a nod to the history of angioplasty than it does modern-day practice: a session dedicated to “learning safe femoral access.” This piece of programming, said Wijns, also sprang from feedback provided by early career cardiologists and fellows. “We heard that because they trained in the radial approach they are now scared of the prospect of femoral complications” when they need to fall back on this approach, he explained. “That’s amazing.”