The 30th annual Transcatheter Cardiovascular Therapeutics (TCT) conference 2018 held in sunny San Diego, California, was replete with surprises. The landmark COAPT trial was a clear home run, showcasing that transcatheter mitral valve approximation using the MitraClip, on a background of maximally tolerated guideline-directed medical therapy (GDMT) was superior to GDMT alone in the reduction of Heart Failure (HF) hospitalization and mortality in symptomatic heart failure patients with grade

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... Mitral regurgitation (MR). Spectacularly, device-based treatment resulted in a significantly lower rate of hospitalization for heart failure, lower mortality, and better quality of life and functional capacity within 24 months of follow-up than medical therapy alone. As similar trials in Europe had been negative and the surgical literature for functional MR ran along the same lines, the low expectations made the contrasting results appear all the more staggering. Interventionalists attributed these findings to endpoints such as repeat hospitalization for heart failure and the meticulously selected population, stating effectiveness in the real world would hinge on how closely doctors could replicate the enrolled patient group. Indeed, 'MitraClip should be done for the right reasons in the right group of patients,' was the take-home message. Delving deep into the coronary microvasculature, the CorMicA trial paved the way for new insights into mechanisms and disease-modifying therapy for angina patients with no obstructive coronary artery disease (CAD). Ford et al. demonstrated how adjunctive testing of coronary vascular function during coronary angiography followed by medical therapy targeted to the findings, improved angina outcomes. While the results were only applicable to severely symptomatic patients at baseline, there was no denying the fact that microvascular angina could be extremely disabling, underlining the importance of titration of therapies in afflicted patients. PREPARE-CALC was based on the concept that heavily calcified de novo coronary lesions were difficult and needed to be prepared using balloon modification techniques (MB) or upfront high-speed rotational atherectomy (RA) in order to allow successful stent implantation. Dr. Gert Richardt reported excellent success rates with strategy success being significantly more common in the RA vs MB group (98% versus 81%). Moreover, patients had a crossover to RA in case MB failed, with an extraordinarily high success rate in this group. Dr.Richardt spoke about the possibility of bailout or 'Rota-regret' stating, "Depending on your experience and preference, you can do the heavily calcified lesions either with upfront rotablation electively or you can start with a balloon. But if you start with the latter, you have to be prepared for a crossover or a bailout situation. Either way, you have to be trained in the technique of rotational atherectomy." While the results of the trial were expected, it was a good question to raise, keeping in mind the shorter duration and cost-effectiveness of MB, in comparison with RA. In the long saga of ABSORB trials, the encouraging results of ABSORB IV showed that polymeric coronary bioresorbable vascular scaffolds (BVS) were non-inferior to cobalt-chromiumbased Xience DES for cardiovascular outcomes of target lesion failure and angina in fairly simple lesion types, in a 1 year period. Although the results were better for BVS compared with ABSORB III, there was also an improvement in the results in the Xience DES arm. Comparing the study to ABSORB III, the primary investigator, Dr. Stone commented, "It was a very, very interesting study. Better technique, better patient selection, and appropriate types of lesions do bring down this difference and I honestly believe that now all we need is a better device that will hopefully eliminate most or all of these early first 3 year differences, potentially allowing the long-term benefits of ABSORB to emerge."