Drug-coated balloons are exactly what the name suggests: angioplasty balloons coated with an antiproliferative drug, most commonly paclitaxel, that is transferred to the artery wall during a brief inflation. The drug suppresses the cellular overgrowth that causes arteries to renarrow, while the balloon itself leaves no permanent metallic scaffold behind. Drug-eluting stents, by contrast, combine a metallic mesh with a polymer that slowly releases a similar antiproliferative agent. Stents have dominated interventional cardiology since the second-generation devices proved themselves in landmark trials, and they remain the guideline-recommended treatment for newly diagnosed coronary lesions. DCBs, meanwhile, are already established and guideline-endorsed for treating in-stent restenosis, the renarrowing that occurs inside an existing stent, but their role in de novo disease, meaning lesions that have never been treated before, has remained an open question.

The appeal of a stentless strategy is considerable. By avoiding a permanent metallic implant, DCB angioplasty may preserve the artery’s natural vasomotor function, reduce the chronic inflammatory stimulus that a foreign body imposes, eliminate the risk of mechanical stent failure such as fracture or strut malapposition, and potentially allow shorter courses of dual antiplatelet therapy in selected patients. It also leaves future surgical or percutaneous revascularisation options unobstructed. In small vessels, where stent struts occupy a proportionally greater fraction of the lumen and raise the metal-to-artery ratio, these advantages are particularly relevant, and a recent patient-level meta-analysis found that DCBs actually reduced major adverse cardiovascular events compared with stents in small-vessel disease, a finding expected to influence future interventional guidelines.

What has been missing is high-quality randomised evidence in the broader, all-comer population of de novo coronary disease. That gap began to close with the publication of two large trials: REC-CAGEFREE I, which randomised 2272 patients in China across 43 centres, and SELUTION De Novo, a 3323-patient trial conducted across 62 centres in Europe and Asia. The new meta-analysis incorporates both, along with eight earlier trials, to produce the most contemporary synthesis available. The researchers systematically searched PubMed, Embase, and Scopus from inception to 30 May 2026, screening 2510 abstracts and ultimately including ten studies that compared DCB-only with DES-only percutaneous coronary intervention, required second-generation or newer stents in the comparator arm, and reported at least twelve months of follow-up.

Because trial-level definitions of major adverse cardiovascular events varied widely, the researchers analysed the individual components separately: cardiovascular death, myocardial infarction, and target lesion or target vessel revascularisation. The results were striking in their consistency. Cardiovascular death showed no significant difference between strategies, with an odds ratio of 1.06 and zero heterogeneity across trials. Myocardial infarction likewise showed no difference, with an odds ratio of 1.02. Critically, when the researchers excluded the four small-vessel-only trials to examine all-comer vessel sizes, the findings held: cardiovascular death yielded an odds ratio of 1.01 and myocardial infarction an odds ratio of 1.06, both statistically indistinguishable from no difference, with zero heterogeneity in every analysis.

Revascularisation told a more complicated story. Across all ten trials, there was no significant difference in target lesion or target vessel revascularisation between the two strategies, with an odds ratio of 1.39 and moderate heterogeneity. But when small-vessel-only studies were excluded, the picture changed: DCB-treated patients experienced significantly higher rates of repeat revascularisation, with an odds ratio of 1.84 and a p-value of 0.03. This finding, however, was heavily influenced by a single trial. When REC-CAGEFREE I was removed in a leave-one-out sensitivity analysis, the significant difference disappeared entirely. The researchers also noted that revascularisation as an endpoint is inherently vulnerable to variability in clinical judgement, patient preference, and local practice, and that a sensitivity analysis restricted to studies reporting target lesion revascularisation specifically produced consistent results, suggesting the findings were not driven by differences in endpoint definitions.

The divergence between the two largest trials deserves scrutiny. REC-CAGEFREE I, which used the Swide paclitaxel-coated balloon, failed to meet its non-inferiority criterion, driven largely by higher target vessel revascularisation in the DCB arm. SELUTION De Novo, which tested a sirolimus-eluting balloon, met non-inferiority on its intention-to-treat analysis, though the authors of the meta-analysis note that aspects of the non-inferiority margin have been debated and the secondary per-protocol analysis failed to meet the threshold. The two trials also differed fundamentally in design: REC-CAGEFREE I randomised patients after lesion preparation, making it a device trial, whereas SELUTION De Novo randomised before lesion preparation, making it a strategy trial. In DCB angioplasty, where procedural success depends heavily on lesion preparation and appropriate bailout stenting, this distinction matters considerably. Follow-up duration also differed, with REC-CAGEFREE I reporting three-year outcomes and SELUTION De Novo reporting one-year outcomes, leaving open the question of whether the favourable early results will persist.

The meta-analysis also raises a crucial point about device technology: a class effect cannot be assumed. Most of the included trials used paclitaxel-coated balloons, but the pharmacokinetic properties, coating technologies, and excipients differ substantially between devices. The Swide balloon used in REC-CAGEFREE I had limited published clinical evidence before that trial, and the device is not commercially available outside the trial programme. SELUTION SLR, the sirolimus-eluting balloon in the other large trial, uses a different drug and transfer mechanism altogether. Comparative data between sirolimus and paclitaxel-coated balloons remain limited, and early studies suggest broadly similar outcomes, but the authors caution that equivalence between platforms cannot currently be taken for granted. Notably, leave-one-out analyses excluding the sole sirolimus trial yielded consistent findings, suggesting the overall results were not driven by any single platform or antiproliferative agent.

The safety findings extended to thrombosis and to acute coronary syndrome populations. Target lesion thrombosis, reported in six studies covering 7326 patients, showed no statistical difference between strategies, though the point estimate numerically favoured DCB treatment with an odds ratio of 0.54. An exploratory analysis of ACS populations similarly found no significant difference in major adverse cardiovascular events, with an odds ratio of 1.07 and zero heterogeneity. Risk of bias assessment using the Cochrane RoB 2 tool classified seven studies as low risk across all domains, and GRADE assessment yielded moderate certainty for the cardiovascular death and myocardial infarction findings, though only low certainty for revascularisation outcomes. Sensitivity analyses excluding studies with bias concerns and stratifying by follow-up duration did not materially alter the core conclusions, although a time-dependent pattern emerged for revascularisation: the excess with DCB was significant at twelve months but no longer detectable at twenty-four months or beyond.

The authors are careful about the limits of their evidence. The analysis used aggregate trial-level data rather than individual patient records, limiting adjustment for baseline differences. Clinical and methodological heterogeneity was substantial, spanning stable disease and acute coronary syndromes, small vessels and all-comer populations, and twelve to sixty months of follow-up. The results may not generalise to complex lesion subsets such as left main stem disease or chronic total occlusions, which were excluded from the included trials. Several ongoing randomised trials, including TRANSFORM II, CAGE-FREE III, and the Reverse trial, will further define the role of DCB-only intervention across broader de novo coronary disease. For now, the message is measured: drug-coated balloons appear safe across any vessel size within the studied lesion subsets, but the higher revascularisation signal in larger vessels, and the meaningful differences between DCB platforms, mean that stentless angioplasty remains a strategy under active evaluation rather than a settled replacement for the stent.

Subject of Research: Comparison of drug-coated balloons versus drug-eluting stents for treating de novo coronary artery disease

Article Title: Drug coated balloons versus drug eluting stents for de novo coronary artery disease: a systematic review and meta-analysis of randomised controlled trials

Article References: Corballis, N., Natarajan, R., Merinopoulos, I., Tsampasian, V., Clark, A., Eccleshall, S., & Vassiliou, V. S. (2026). Drug coated balloons versus drug eluting stents for de novo coronary artery disease: a systematic review and meta-analysis of randomised controlled trials. eClinicalMedicine, Article 104204. https://doi.org/10.1016/j.eclinm.2026.104204

Image Credits: AI Generated

DOI: 10.1016/j.eclinm.2026.104204

Keywords: drug-coated balloons, drug-eluting stents, coronary artery disease, meta-analysis, randomised controlled trials, percutaneous coronary intervention, target lesion revascularisation, myocardial infarction, cardiovascular death, small vessel disease, interventional cardiology, Drug

The biological rationale for the procedure rests on the peculiar anatomy of the left atrial appendage, a finger-like, trabeculated pouch in the upper left chamber of the heart. In non-valvular atrial fibrillation, the quivering atrium fails to contract properly, blood stagnates, and clots form overwhelmingly in this appendage. The review’s authors describe a broader concept of atrial myopathy, in which abnormal contractility combines with endothelial dysfunction, inflammation, reduced nitric oxide availability, and activation of the renin-angiotensin-aldosterone system to create a prothrombotic environment. Appendage morphology itself matters: autopsy studies have linked a greater number of lobes to thrombus formation, and radiographic classifications such as cactus, chicken-wing, cauliflower, and windsock shapes carry different risks, with non-chicken-wing geometries most closely associated with clot and embolic stroke, possibly because of lower peak-flow velocities within the pouch.

Yet the authors emphasize a crucial mechanistic caveat that any patient considering the procedure should understand. Oral anticoagulation acts systemically, protecting against clots wherever they form, whereas appendage occlusion acts locally. Mechanical exclusion of the appendage cannot prevent thromboembolism arising elsewhere in the heart, nor can it address non-cardioembolic stroke mechanisms such as large-artery atherosclerosis and small-vessel disease, which are common in the elderly, vascular population that develops atrial fibrillation. In the classic Stroke Prevention in Atrial Fibrillation trials, 52 percent of ischaemic strokes were classified as probably cardioembolic, 24 percent as non-cardioembolic, and 24 percent as uncertain; strikingly, among patients on warfarin, 56 percent of breakthrough strokes were non-cardioembolic. Occluding the appendage removes the dominant source of cardioembolism but does not eliminate all sources of stroke.

The technical execution of the procedure has matured considerably since the first percutaneous occlusion in 2001 with the PLAATO device. Contemporary implants follow three design principles: the plug principle, exemplified by the Watchman FLX, in which a lobe obstructs the appendage neck and relies on endothelialization for sealing; the pacifier principle, exemplified by the Amulet, which adds a proximal disc to seal the ostium; and ligation, achieved with the LARIAT device through a combined endocardial and epicardial approach. Implantation is performed through a femoral vein with a transseptal puncture, guided by fluoroscopy alone, transoesophageal echocardiography, or intracardiac echocardiography, each with distinct trade-offs in anaesthesia requirements, radiation exposure, and resource use. Real-world data from 3,822 consecutive procedures in the United States immediately after FDA approval showed a 95.6 percent implant success rate, a median procedure time of 50 minutes, a cardiac tamponade rate of 1.02 percent, and a procedure-related stroke rate of just 0.078 percent, even though 71 percent of operators had not participated in the clinical trials.

The evidence base changed dramatically over the past two years with the reporting of three randomized trials comparing occlusion with direct oral anticoagulants. OPTION randomized 1,600 patients undergoing catheter ablation to appendage closure with the Watchman FLX or continued anticoagulation, finding superior reduction in non-procedure-related bleeding (8.5 versus 18.1 percent) and non-inferior efficacy for death, stroke, or systemic embolism. CHAMPION-AF, the largest trial to date, enrolled 3,000 patients eligible for anticoagulation and demonstrated non-inferiority for the composite of cardiovascular death, stroke, or systemic embolism (5.7 versus 4.8 percent), along with a substantial reduction in non-procedure-related bleeding (10.9 versus 19.0 percent). But the nuances matter: observed event rates were lower than projected, making the non-inferiority margin permissive; ischaemic stroke was numerically more frequent in the device arm (3.2 versus 2.2 percent); and device-related thrombus appeared in 4.8 percent of recipients on imaging.

CLOSURE-AF, by contrast, addressed the population where occlusion is most often performed in practice: 912 older patients at high risk of both stroke and bleeding, or with contraindications to anticoagulation, mean age 77.9 years. After a median follow-up of three years, the primary composite endpoint occurred at 16.8 versus 13.3 events per 100 patient-years, and the trial failed to meet its non-inferiority criterion, with an adjusted hazard ratio of 1.28. The authors argue this should not be read as invalidating the therapy, since individual endpoint components occurred at similar rates and the trial was not powered for them, but it does raise a sobering question about whether the upfront procedural risk is worthwhile in frail patients whose remaining life expectancy may be too short for benefits to accumulate.

Pooling the four randomized trials that compared occlusion with direct oral anticoagulants, a 2026 meta-analysis of 5,890 patients with median follow-up of 36 to 42 months delivers the most informative summary available. The device significantly reduced non-procedure-related major bleeding (relative risk 0.79) and non-major bleeding (relative risk 0.47), but showed no significant difference in all-cause major bleeding, intracranial haemorrhage, all-cause mortality, or cardiovascular death. Most provocatively, the risk of ischaemic stroke was numerically higher with the device (relative risk 1.36), reaching statistical significance once the OPTION trial was excluded (relative risk 1.45). The reviewers argue that observational studies claiming a mortality advantage for the procedure suffer from healthy-candidate bias, since patients accepted for elective structural procedures are systematically fitter than similarly scored patients managed medically, and that survival claims should be limited to what randomized data support, which is currently equivalence.

Device-specific hazards add further layers of complexity. Peri-device leaks greater than 5 millimetres are considered significant, but even smaller leaks have been associated with increased thromboembolic risk at one year, making complete sealing during implantation a priority that modern fully recapturable devices are better positioned to achieve. Device-related thrombus, detected in an international registry of 711 patients at rates approaching 25 percent within 45 days, more than doubles the risk of death, stroke, or systemic embolism, and its predictors include hypercoagulability, renal insufficiency, deep implantation, and non-paroxysmal atrial fibrillation. Head-to-head comparisons suggest the Amulet achieves more complete sealing with fewer device thrombi, while the Watchman carries a lower risk of pericardial effusion, including a network meta-analysis finding a 2.12-fold higher effusion risk with the Amulet, though no device has demonstrated superiority in stroke or mortality outcomes.

The question of what antithrombotic therapy to give after implantation remains among the least resolved aspects of the procedure. Two randomized trials now favour short-term anticoagulation over dual antiplatelet therapy: the ANDES trial of 510 patients found the composite of death, stroke, bleeding, or device-related thrombus significantly lower with a direct oral anticoagulant (22.5 versus 34.9 percent), primarily due to less bleeding. For patients who cannot tolerate any anticoagulation, single antiplatelet therapy or even complete cessation may be considered, with one large series of 431 high-bleeding-risk patients showing a 1-year ischaemic stroke rate of 2.2 percent despite 41.7 percent receiving no antithrombotic therapy at six months, but the supporting evidence remains observational and the authors recommend reserving complete withdrawal for patients in whom every antithrombotic agent poses prohibitive bleeding risk, following documented exclusion of device thrombus and significant leak.

The bottom line, according to the review, is that appendage occlusion is an established option for patients with contraindications to or intolerance of long-term anticoagulation, and OPTION now supports it as a reasonable alternative in patients undergoing ablation. For the broader population of patients who tolerate direct oral anticoagulants well, the procedure has become a randomized-tested alternative, but the evidence supports an individualized, shared decision rather than a universal offer. Ongoing trials such as CATALYST, which compares the Amulet with anticoagulation in 2,650 patients, and studies enrolling patients after intracranial haemorrhage, will help define the boundaries further. Until then, the authors contend, honest counselling about upfront procedural risks, residual non-appendage stroke mechanisms, and the true magnitude of the bleeding benefit should guide a therapy that has been evocatively described as a mechanical vaccination, provided that metaphor never obscures what the procedure cannot do.

Subject of Research: Left atrial appendage occlusion as a mechanical alternative to oral anticoagulation for stroke prevention in atrial fibrillation

Article Title: Left atrial appendage occlusion: an alternative to anticoagulation in atrial fibrillation

Article References: Messaoudi, Y., Roux, O., Monney, P., Muller, O., & Nietlispach, F. (2026). Left atrial appendage occlusion: an alternative to anticoagulation in atrial fibrillation. Frontiers in Cardiovascular Medicine, 13, Article 1889918. https://doi.org/10.3389/fcvm.2026.1889918

Image Credits: AI Generated

DOI: 10.3389/fcvm.2026.1889918

Keywords: atrial fibrillation, left atrial appendage occlusion, stroke prevention, oral anticoagulation, direct oral anticoagulants, Watchman FLX, Amulet, device-related thrombus, peri-device leak, randomized controlled trials, meta-analysis, interventional cardiology

Coronary angiography, in which dye is injected into the heart’s arteries while X-ray video is recorded, remains the reference standard for diagnosing coronary artery disease, the world’s leading cause of death. Yet the interpretation of those videos is strikingly inconsistent. Visual assessment of stenosis, the narrowing of a vessel, varies between observers by anywhere from 7.6 to 22.5 percent, and the problem is worse when a single physician reads the study alone. Prior research cited by the team suggests that overestimation of stenosis severity occurs in more than a quarter of cases, potentially contributing to inappropriate coronary interventions in roughly 17 percent of bypass surgery cases and 10 percent of stent procedures. That variability has long motivated efforts to bring objective, reproducible measurement into the catheterization laboratory.

Earlier AI systems made progress but were limited in scope. CathAI, a previous model from some of the same investigators, achieved an area under the receiver operating characteristic curve, or AUROC, of 0.86 for detecting epicardial stenoses, while a follow-up video model called DeepCORO showed that temporal information across frames improves analysis. But these tools processed single videos or frames, relied on multistep pipelines rather than end-to-end training, and were optimized for one task at a time. DeepCORO-CLIP takes a fundamentally different approach, borrowing from vision-language models such as CLIP and their medical descendants like EchoCLIP and EchoPrime in echocardiography. Instead of learning from labeled examples of a single disease, it learns a shared representation between angiographic video and the free-text reports cardiologists write, allowing one encoder to support many downstream tasks.

The training data were enormous by the standards of cardiac imaging. The team screened 940,366 video-report pairs and, after excluding videos contaminated by procedural equipment, lacking contrast, or acquired after stenting or in patients with prior bypass surgery, assembled 203,808 videos from 28,117 patients, spanning 32,473 studies and 56,299 reports. The cohort, drawn from seven years at one of Canada’s highest-volume catheterization centers, had a mean age of 67.3 years and was 66.6 percent male, with a heavy burden of hypertension, diabetes and prior intervention. In the first training phase, a Multiscale Vision Transformer encoder learned to align each video with its paired report text using a contrastive objective. In the second phase, the pretrained encoder was fine-tuned with a multi-instance learning framework that uses gated attention to aggregate information across all of a study’s videos, generating predictions for 18 coronary segments across four tasks simultaneously.

The diagnostic results were strong. For detecting obstructive stenosis of 70 percent or greater, the model achieved a micro-averaged AUROC of 0.89 both internally and in external validation at UCSF, with sensitivity of 0.85 and specificity of 0.70 at the operating point chosen. It identified chronic total occlusion with AUROCs of 0.90 to 0.95, and detected intracoronary thrombus, a rare finding present in only 0.25 percent of segments, with an AUROC of 0.90. Moderate-to-severe calcification was graded with AUROCs of 0.90 to 0.91. Notably, the contrastively pretrained encoder outperformed a baseline video model initialized on the general-purpose Kinetics-400 dataset across every task, with the largest gains on rare phenotypes, and it beat a latent-predictive alternative encoder on stenosis, calcification and occlusion detection despite that competitor having ten times more parameters. Multiview attention pooling consistently improved accuracy over analyzing single videos or simply averaging their outputs.

Perhaps the most striking finding is prognostic. When fine-tuned on 1,047 patients with follow-up data and tested on 350 others, the model predicted composite major adverse cardiovascular events, including urgent revascularization, nonfatal heart attack and complete coronary occlusion, within one year with an AUROC of 0.79, compared with 0.65 for a logistic-regression model built from conventional clinical variables. Risk stratification separated patients into three groups with hazard ratios of 5.6 and 18.6 for the intermediate and high-risk groups relative to the low-risk reference. Remarkably, adding clinical variables to the model’s risk score did not improve discrimination, suggesting that the angiographic video itself, capturing disease extent, lesion severity and territorial distribution, already contains most of the prognostic signal. The model also estimated left ventricular ejection fraction from coronary angiograms alone with a mean absolute error of 7.3 percent, bettering the 8.8 percent of a previous dedicated model.

Against expert consensus, the machine held its own. In a core laboratory adjudication of 662 studies and 965 lesions, where two interventional cardiologists independently quantified stenosis using quantitative coronary angiography, DeepCORO-CLIP’s predictions deviated from the adjudicated values by a mean of 13.6 percentage points, compared with 19.0 points for the original clinical reports. The clinical reports turned out to be systematically conservative, missing nearly half of QCA-positive lesions, while the model’s errors were more evenly distributed. In error analysis across nearly 4,800 test catheterizations, the model correctly flagged at least one treated vessel in 85.8 percent of patients who underwent stenting, and a normal prediction reliably excluded obstructive disease, with negative predictive value exceeding 98 percent across all segment categories. Its main weakness was distal and branch vessels, where small caliber limits visualization and severity correlation collapsed toward zero.

The team also tested the model in the messiest setting of all: writing reports. In a prospective, blinded reader study, two independent cardiologists evaluated 365 interpretations across 288 angiograms, mixing AI-generated reports with those written by the operating physicians. Readers judged the AI reports clinically usable in 76 percent of evaluations versus 88 percent for physicians, with the gap driven almost entirely by omissions rather than fabrication. Hallucinated findings appeared no more often in AI reports than in human ones, 17 percent versus 14 percent, a difference that was not statistically significant. The unacceptable AI reports almost always involved missed proximal stenoses, and a threshold analysis showed those misses reflected the deliberately conservative 0.50 probability cutoff used by the report generator rather than a blind spot in the model itself. Loosening the threshold recovered most missed lesions but roughly halved precision, a trade-off the researchers have left as a user-configurable parameter in the released code.

Deployment is already underway. Using a bespoke platform called PACS-AI, angiography studies stream from the catheterization laboratory to the hospital’s picture archiving system, where DeepCORO-CLIP runs automatically with an end-to-end latency of 4.2 seconds, fast enough to inform decisions during the procedure itself. The model weights are freely available under an open license, and the code is released for noncommercial research. The authors are careful about limitations: the study was retrospective, external validation covered a single additional center, patients with prior bypass surgery were excluded, and the cohort was predominantly male. Follow-up for event prediction was also short. Still, the trajectory is clear. A single model, trained on routine clinical data without task-specific labels, now reads a complete multiview angiogram, quantifies disease, characterizes lesions, estimates heart function, predicts one-year risk and drafts a report in seconds. Whether it ultimately reduces inappropriate interventions or simply becomes a tireless second reader, the era of the general-purpose angiography interpreter has arrived.

Subject of Research: A multiview video-text AI model for interpreting coronary angiography to detect stenosis and predict cardiovascular events

Article Title: A multiview video–text model detects obstructive coronary stenosis and predicts 1-year cardiovascular events from angiography

Article References: Harrabi, S., Wu, Y., Majwal, O., Asslo, G., Azar, G., Tison, G. H., Ansari, M., Vukadinovic, M., Ouyang, D., Barrios, J. P., Delfrate, J., & Avram, R. (2026). A multiview video–text model detects obstructive coronary stenosis and predicts 1-year cardiovascular events from angiography. Nature Cardiovascular Research. https://doi.org/10.1038/s44161-026-00890-8

Image Credits: AI Generated

DOI: 10.1038/s44161-026-00890-8

Keywords: coronary angiography, artificial intelligence, vision-language model, coronary artery disease, stenosis detection, cardiovascular risk prediction, deep learning, interventional cardiology, chronic total occlusion, left ventricular ejection fraction, foundation model, clinical AI deployment

Professor Renate Schnabel of Hamburg will serve as congress president for the main Herztage program, which is published under the banner Kardiologie Aktuell. Schnabel is a well-known figure in cardiovascular epidemiology and heart-failure research, and her appointment signals a program expected to bridge population-level cardiovascular science with clinical practice. The rhythm-focused Deutsche Rhythmus Tage will be led by Priv.-Doz. Anja Schade of Bad Neustadt, while Professor Tanja Katharina Rudolph of Bad Oeynhausen will preside over AGIK Live, the interventional component of the meeting.

Basic science receives dedicated organizational attention at the congress. Professor Harald Langer of Mannheim and Professor Rabea Hinkel of Göttingen will organize the Basic Science Meeting, a strand designed to connect laboratory-level cardiovascular research with translational and clinical audiences. In addition, the Akademieforen, a series of academy forums aimed at continuing medical education, will be coordinated by Professor Christiane Tiefenbacher of Wesel and Professor Albrecht Elsässer of Oldenburg. This layered structure reflects the congress’s dual role as a scientific meeting and a professional training platform for German-speaking cardiology.

The scientific program is supported by a searchable online abstract database, accessible through the congress website at herzmedizin.de. According to the announcement, the database allows physicians and allied professionals to search documents by keyword, giving attendees a tool to navigate the full scientific program before arriving in Hamburg. Abstract-driven sessions remain a core mechanism through which new clinical trial results, registry analyses, and mechanistic studies enter the public record at European cardiology meetings.

The venue itself carries weight in the European cardiology calendar. The Congress Center Hamburg is a regular host for large medical congresses, and a late-September slot positions the Herztage after the summer lull in the conference season and ahead of the autumn wave of major international meetings. For German cardiovascular medicine, the Herztage function as the principal national forum where late-breaking science, guideline updates, and health-policy debates converge under one roof.

The announcement appeared in Clinical Research in Cardiology, the official journal of the German Cardiac Society, published by Springer Nature. The journal serves as a standing venue for society communications, original research, and reviews in cardiovascular medicine, and its publication of the congress notice gives the meeting details a citable, version-of-record home. The published record notes that Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations, a standard publisher’s note for internationally distributed academic content.

For clinicians planning continuing education, the division of the congress into distinct strands matters practically. The main Herztage program under Schnabel typically spans the breadth of cardiovascular medicine, while the Deutsche Rhythmus Tage under Schade concentrates on arrhythmia management, including device therapy and electrophysiology. AGIK Live, under Rudolph, is associated with the Arbeitsgemeinschaft Interventionelle Kardiologie, the interventional cardiology working group of the German Cardiac Society, and traditionally features live case transmissions from catheterization laboratories, a format that lets attendees observe real-time procedural decision-making.

The basic science meeting organized by Langer and Hinkel underscores a broader trend in European cardiology congresses: the deliberate integration of molecular and preclinical research into clinically oriented programs. Hinkel’s work in cardiovascular gene therapy and regenerative approaches, and Langer’s background in thrombosis and platelet biology, illustrate the translational orientation that the organizers bring to this strand. By pairing basic scientists with clinical leadership across the congress, the German Cardiac Society positions the Herztage as a venue where bench-to-bedside conversations are structurally embedded rather than incidental.

The Akademieforen, coordinated by Tiefenbacher and Elsässer, extend the congress’s educational reach. These forums are designed as interactive academy sessions rather than passive lecture formats, and they typically address case-based learning, guideline application, and emerging diagnostic and therapeutic techniques. Their inclusion alongside the scientific and interventional strands reflects the society’s effort to serve trainees, established clinicians, and allied professionals within a single meeting architecture.

Registration and program details are distributed through the German Cardiac Society’s congress platform, and the abstract database linked in the announcement is expected to grow as submission cycles close. With the congress presidents named and the Hamburg dates fixed, the organizational skeleton of DGK Herztage 2026 is now public, giving researchers, clinicians, and industry participants the framework they need to plan submissions, sessions, and attendance for what remains the flagship annual meeting of German cardiovascular medicine.

Subject of Research: The DGK Herztage 2026 cardiology congress announcement

Article Title: DGK Herztage 2026

Article References: DGK Herztage 2026. (2026). Clinical Research in Cardiology, 115(11), 2084. https://doi.org/10.1007/s00392-026-03036-9 (Author names are not included in the publisher’s citation export.)

Image Credits: AI Generated

DOI: 10.1007/s00392-026-03036-9

Keywords: cardiology, DGK Herztage 2026, German Cardiac Society, Hamburg, clinical research, arrhythmia, interventional cardiology, basic science, medical congress, Clinical Research in Cardiology, continuing medical education, cardiovascular medicine

The research team, led by Mohammed Abusharekh and Amir Abbas Mahabadi, compared the original PASCAL repair system with its second-generation iteration, the PASCAL ACE, in a cohort of 366 consecutive patients treated between 2019 and 2024. The PASCAL system, developed by Edwards Lifesciences, introduced a central spacer and independent leaflet capture as structural innovations over the earlier MitraClip platform. The ACE version refined the concept further, featuring a reduced profile, narrower paddles, and increased curvature designed to enhance leaflet approximation, improve deliverability, and distribute mechanical stress more evenly in anatomically challenging valves. Until now, however, head-to-head comparative data in real-world practice have been scarce, leaving device selection largely to operator judgment.

The Essen cohort reflected the realities of contemporary practice. Patients had a mean age of 77.7 years, and nearly 58 percent were men. All had moderate-to-severe or severe mitral regurgitation, categorized by etiology as functional, degenerative, or mixed. Crucially, the two devices were not used interchangeably. Patients receiving the ACE device were older, more frequently had atrial fibrillation, and presented with significantly more complex valve anatomy, including bileaflet or multi-scallop prolapse in 25.8 percent of cases compared with 13.1 percent in the PASCAL group. Moderate-to-severe calcification in the grasping area, leaflet clefts, and restricted leaflet mobility were also more common in the ACE cohort. In other words, clinicians were already intuitively reserving the refined device for the hardest cases.

To move beyond intuition, the investigators deployed comprehensive three-dimensional transesophageal echocardiography before and during every procedure. This imaging approach allowed precise planimetric measurement of the mitral valve orifice area, or MVOA, in late diastole at maximal leaflet opening, along with the vena contracta area, anteroposterior and mediolateral annular diameters, annular area, perimeter, and the annular sphericity index. All 3D datasets were analyzed offline by a senior echocardiographer blinded to device type and outcomes, a methodological safeguard that lends considerable weight to the findings. Procedural endpoints followed the Mitral Valve Academic Research Consortium criteria, and statistical analysis included multivariable regression and propensity score matching to address the inherent selection bias of a non-randomized comparison.

The headline result concerns the fate of the valve orifice. Before the procedure, ACE-treated patients had larger baseline orifice areas, a median of 6.55 square centimeters versus 5.87 square centimeters in the PASCAL group. After the first device was implanted, the ACE group predictably retained a larger residual orifice, 3.81 versus 3.38 square centimeters. But when the researchers calculated the relative reduction, the numbers were almost identical: a decrease of 44.5 percent with ACE versus 45.9 percent with PASCAL, a difference that did not reach statistical significance. This pattern held consistently across functional, degenerative, and mixed etiologies. In essence, both devices squeezed the valve by roughly the same proportion; the final orifice size simply mirrored what the anatomy had provided at the start.

The hemodynamic consequences followed the same logic. The transmitral mean pressure gradient, a key indicator of potential iatrogenic mitral stenosis, rose modestly in both groups, with a slightly smaller increase in the ACE cohort, from one to two millimeters of mercury difference, likely reflecting the larger residual orifice areas in that group. This detail matters clinically, because accumulating evidence suggests that a post-procedural mean gradient of five millimeters of mercury or higher predicts worse outcomes. Whether the modest gradient advantage observed with ACE after the first device translates into long-term clinical benefit remains an open question that the study’s authors flag for future investigation.

Annular remodeling told a similar story of convergence. Both devices shifted the mitral annulus from a circular toward a more elliptical geometry, with comparable relative reductions in the anteroposterior diameter and the annular sphericity index. The slightly larger post-procedural annular dimensions in the ACE group, including a small increase in mediolateral diameter, were best explained by the larger baseline annular size rather than any device-specific geometric effect. Notably, no differences in annular sphericity or transmitral gradients emerged across any of the etiological subgroups, reinforcing the conclusion that the two devices exert fundamentally similar geometric influences on the valve apparatus.

One area where the devices diverged was the need for a second implant. ACE-treated patients more often required two devices, 35.9 versus 23.5 percent, and had a larger residual vena contracta area after the first implant, particularly in degenerative regurgitation where multi-scallop prolapse and bileaflet involvement predominated. Yet after the second device, final vena contracta values and percent reductions were comparable between groups, supporting multi-device strategies as a reliable path to procedural optimization regardless of starting anatomy. Procedural success was uniformly excellent, 100 percent with ACE and 99.6 percent with PASCAL, with no cases of single leaflet device attachment, leaflet injury, or chordal entrapment in either cohort.

The study also documented a clear temporal shift in practice. In the early years, the original PASCAL device accounted for the majority of procedures, but after ACE was introduced at the center in August 2020, its utilization climbed steadily and eventually became the dominant choice. This evolution parallels a rising proportion of patients presenting with complex valve morphology and mixed etiologies, suggesting that the refined device arrived just as the treated population was becoming more challenging. A sensitivity analysis comparing the first fifty PASCAL cases with later ones showed that operator experience improved acute efficacy without compromising safety, partially addressing concerns about a learning curve.

Perhaps the most consequential finding came from the multivariable analysis. After adjusting for age, atrial fibrillation, ejection fraction, etiology, anatomical complexity, baseline dimensions, and temporal trends, the differences in post-procedural orifice and vena contracta areas that appeared in the crude comparison vanished entirely. Device type was not an independent predictor of any geometric or hemodynamic outcome. A stratified analysis by baseline valve size added nuance: device-specific effects on narrowing only emerged in mid-sized valves, where ACE proved more area-sparing in the four-to-five square centimeter range, while at the extremes the underlying leaflet anatomy reigned supreme. The authors’ conclusion is unambiguous: baseline valve anatomy, rather than device selection, is the predominant determinant of post-procedural geometry and hemodynamics. For the growing number of heart teams weighing PASCAL against PASCAL ACE, the message is to choose based on the valve in front of them, favoring the ACE’s narrower paddles for complex, restricted, or calcified anatomies and the original PASCAL’s broader coaptation zone where wide leaflet grasping is needed, always guided by meticulous three-dimensional imaging rather than by any assumption that one device is inherently superior.

Subject of Research: Three-dimensional mitral valve geometry and outcomes after transcatheter edge-to-edge repair comparing PASCAL and PASCAL ACE devices

Article Title: Three-dimensional mitral valve geometry after transcatheter edge-to-edge repair: PASCAL versus PASCAL-ACE—implications for devices selection

Article References: Abusharekh, M., Kampf, J., Schindhelm, F., Jürgens, F., Dykun, I., Al-Rashid, F., Totzeck, M., Rassaf, T., & Mahabadi, A. A. (2026). Three-dimensional mitral valve geometry after transcatheter edge-to-edge repair: PASCAL versus PASCAL-ACE—implications for devices selection. Clinical Research in Cardiology. https://doi.org/10.1007/s00392-026-03031-0

Image Credits: AI Generated

DOI: 10.1007/s00392-026-03031-0

Keywords: mitral regurgitation, transcatheter edge-to-edge repair, PASCAL, PASCAL ACE, 3D echocardiography, mitral valve orifice area, annular remodeling, interventional cardiology, degenerative mitral regurgitation, functional mitral regurgitation, device selection, heart team

Transfemoral TAVI has become the treatment of choice for patients with severe aortic stenosis who face elevated surgical risk, and its use is steadily expanding into lower-risk populations. The procedure involves threading a collapsible replacement valve through the femoral artery to the heart, a route that demands large-bore sheaths, often 14 French or larger, to deliver the prosthesis. In the technique’s early years, major vascular complications occurred in roughly 15 percent of patients, a figure that made the femoral access site the most dangerous few centimetres of the entire operation. The protection wire technique, introduced in 2010, was conceived as an insurance policy: an additional guidewire placed via the ipsilateral or contralateral femoral artery, providing immediate endovascular access for percutaneous bailout if catastrophic injury occurred at the primary puncture site.

But the landscape has shifted dramatically since 2010. Lower-profile delivery systems, ultrasound-guided puncture, refined vascular closure strategies, and the growing use of transradial secondary access have pushed major vascular complication rates below 2 percent in low-risk populations. Against that backdrop, the protection wire has begun to look less like a safety net and more like a source of its own problems, because it requires an additional arterial puncture that must itself be managed, compressed, and closed. The Mainz team, led by Marc Adrian Rogmann and Martin Geyer, exploited a natural experiment embedded in their institutional practice: until November 2021, protection wire placement was standard of care for every transfemoral TAVI, after which the wire was abandoned except in operator-selected high-risk cases.

The results were striking. The composite of minor and major vascular complications, classified according to the Valve Academic Research Consortium-3 criteria, occurred in 18.6 percent of patients in the routine protection wire era compared with just 10.8 percent after the protocol change, a difference that was highly statistically significant. Major vascular complications were numerically less frequent without routine wire use, at 2.5 percent versus 4.2 percent, and in-hospital mortality was low and comparable between the two groups, at 2.3 percent and 2.8 percent respectively. Most tellingly, 34.8 percent of all access-related vascular complications in the routine wire group were directly attributable to the protection wire access itself, with the vast majority being minor bleedings at the ipsilateral distal femoral puncture site.

The technical explanation for this pattern is instructive. The protection wire access point, typically a small distal puncture through a 4 French sheath, is not covered by the primary closure device or the pressure dressing applied at the main access site. The researchers propose that many of these injuries arose not from technically inadequate punctures but from insufficient haemostatic compression at a site that the standard closure routine simply overlooks. In the routine wire group, 80.1 percent of protection wires were positioned ipsilaterally, meaning two punctures in the same femoral artery, one of which received far less haemostatic attention. The wire was actively used for intervention in only 25 cases, or 3.1 percent of the routine group, suggesting that the insurance policy paid out far less often than it cost in collateral injury.

Bleeding metrics reinforced the picture. Type 1 and type 2 bleedings under the VARC-3 classification occurred significantly less often without routine wire placement, at 3.3 percent versus 6.1 percent and 3.3 percent versus 7.6 percent respectively. The median haemoglobin drop was smaller in the wire-free era, decreases greater than 3 grams per decilitre were less frequent, and post-procedural haemoglobin values were slightly higher. Procedural times were marginally shorter without the wire, fluoroscopy times were essentially identical, and blood transfusion rates remained low and comparable, indicating that omitting the wire imposed no penalty on procedural efficiency or safety rescue capability.

In a multivariable logistic regression model covering 1,417 patients, the absence of a routine protection wire was independently associated with a lower risk of vascular complications, with an odds ratio of 0.52 and a 95 percent confidence interval of 0.38 to 0.72. Female sex emerged as an independent predictor of increased risk, with an odds ratio of 1.82, consistent with prior evidence attributing the excess to smaller vessel diameters and greater vessel fragility. The closure strategy also mattered: a combination of two suture devices plus one plug-based device was associated with higher odds of complications than suture-only closure, although the authors caution that this combination was typically deployed as a rescue when primary suture haemostasis failed, introducing confounding by indication that limits generalisation.

The findings sit in tension with the SURF-TAVR registry, the largest multicentre study of protection wire use to date, which reported fewer major vascular complications with routine wire placement, at 1.1 percent versus 2.4 percent. The Mainz authors point to important procedural differences: their routine wire era relied exclusively on angiographic rather than ultrasound-guided puncture, their secondary access was predominantly transradial rather than femoral, and their wire placement was overwhelmingly ipsilateral. Both studies, however, converge on one consistent message: overall vascular complication rates were higher with routine protection wire use, driven mainly by minor secondary-access injuries. The authors are candid about the limitations of their before-and-after design, acknowledging that calendar time, evolving case mix, and concurrent refinements in technique cannot be fully disentangled from the wire strategy itself, and that a prospective randomised trial would be needed to isolate the effect.

Nevertheless, the study’s strengths lend it weight. All patients were included consecutively, outcomes were assessed with standardised VARC-3 definitions, and the systematic documentation of complications by individual access site offers a granularity that multicentre registries cannot match. As TAVI continues its expansion into broader and lower-risk populations, the message from Mainz aligns with the broader minimalist turn in structural heart intervention: minimise access burden, favour ultrasound-guided puncture, choose closure devices carefully, and reserve the protection wire for the individual patients whose anatomy and risk profile genuinely warrant it. In contemporary practice, the best safety wire may be the one you never place.

Subject of Research: Impact of routine versus selective femoral protection wire use on vascular complications in transfemoral TAVI

Article Title: Routine versus selective use of a femoral protection wire in transfemoral TAVI: a single-centre analysis of vascular complications

Article References: Rogmann, M. A., Klingemann, V., Meertens, M., Ahoopai, M., Rommel, K.-P., Lurz, P., von Bardeleben, R. S., & Geyer, M. (2026). Routine versus selective use of a femoral protection wire in transfemoral TAVI: a single-centre analysis of vascular complications. Clinical Research in Cardiology. https://doi.org/10.1007/s00392-026-03015-0

Image Credits: AI Generated

DOI: 10.1007/s00392-026-03015-0

Keywords: TAVI, vascular complications, protection wire, femoral access, VARC-3, transcatheter aortic valve implantation, vascular closure devices, transradial access, aortic stenosis, bleeding events, interventional cardiology, Routine

The two dominant technologies at the heart of this debate are intravascular ultrasonography (IVUS) and optical coherence tomography (OCT). IVUS uses a miniaturized ultrasound transducer mounted on a catheter to generate cross-sectional images of the vessel wall, penetrating deeply enough to visualize the full plaque burden and the external elastic lamina. OCT, by contrast, employs near-infrared light to achieve resolution roughly ten times finer than ultrasound — on the order of 10 to 20 micrometers — allowing clinicians to identify thin-cap fibroatheromas, macrophage infiltration, microchannels, calcium thickness, and dissection planes with unprecedented detail. The trade-off is penetration depth: OCT light struggles to see beyond roughly 1 to 2 millimeters of tissue, whereas ultrasound reaches the adventitia. Together they offer complementary windows onto the pathology that angiography misses.

The cumulative randomized evidence now indicates that imaging-guided percutaneous coronary intervention (PCI) delivers measurable prognostic benefit over angiography guidance alone, but with important heterogeneity. The Korean IVUS-XPL and ULTIMATE trials showed reduced major adverse cardiac events with IVUS guidance in long lesions and in mixed populations. RENOVATE-COMPLEX-PCI and IVUS-ACS extended this signal to complex lesions and acute coronary syndromes. On the OCT side, OCCUPI demonstrated fewer device-oriented composite endpoints in complex lesions, and OCTOBER showed that OCT guidance dramatically improved outcomes in true bifurcation stenting, reducing target-vessel failure by roughly a third compared with angiography. Notably, ILUMIEN IV in North America and IVUS-CHIP in Europe failed to reach their primary endpoints, underscoring that trial design, protocol intensity, operator expertise and patient mix all shape whether imaging’s theoretical advantages translate into clinical gains.

One of the most consistent findings across the pooled datasets is that the benefit of imaging scales with lesion complexity. Simple, short, non-calcified lesions in large vessels rarely benefit measurably — the angiogram usually suffices. But in left main coronary interventions, true bifurcations, long diffuse disease, chronic total occlusions, and heavily calcified plaques, imaging changes management decisions in a substantial fraction of cases: stents are sized larger, placed longer, and dilated more aggressively. In the OCTOBER bifurcation population, for example, OCT uncovered extensive unintended stent deformation after side-branch techniques, deformities invisible on the angiogram that imaging-guided optimization could correct. Meta-analyses, including network meta-analyses by Stone and colleagues and by Giacoppo and colleagues, converge on the conclusion that both OCT and IVUS guidance reduce cardiac mortality, stent thrombosis and repeat revascularization relative to angiography alone, without meaningful differences between the two modalities in head-to-head comparisons such as OCTIVUS and OPINION.

The mechanistic explanation for the survival benefit is procedural. Imaging-guided PCI consistently results in larger post-dilatation balloons, larger and longer stents, greater minimal stent area, and more complete coverage of the diseased segment. Registry data going back to the HORIZONS-AMI substudies and the seminal work of Fujii have linked stent underexpansion and residual reference stenosis to acute and late stent thrombosis — the most feared complication of PCI, carrying high mortality. Imaging makes these failure modes visible before the patient leaves the catheterization laboratory. Achieving prespecified optimization criteria — typically a minimal stent area of 5.0 square millimeters by OCT or 5.5 square millimeters by IVUS in distal references, plus full lesion coverage — has been repeatedly associated with improved long-term outcomes, although the review’s authors stress that pursuing these numeric thresholds must never come at the cost of procedural safety, for instance by forcing oversized balloons into vessels at risk of rupture.

Patient subgroups add further nuance. In acute coronary syndromes, imaging characterizes the culprit plaque, identifies plaque rupture and erosion, detects residual thrombus, and helps distinguish which lesions truly warrant stenting — particularly valuable when multiple lesions compete for attention. Patients with diabetes mellitus, whose plaques tend to be diffuse and negatively remodeled, and those with chronic kidney disease, who face elevated event rates after PCI, appear to derive particular prognostic benefit from imaging-guided optimization in complex anatomy, as shown in analyses from ULTIMATE and from the JAMA Network Open cohort of Kwon and colleagues. Conversely, in straightforward lesions, the added contrast injections, catheter exchanges, cost, and procedural time may not be justified. Current guidelines reflect this gradient: the 2024 European Society of Cardiology chronic coronary syndrome guidelines give imaging a class IIa recommendation for stent sizing and optimization, while the 2025 American ACC/AHA acute coronary syndrome guideline similarly endorses imaging use in selected settings.

The barriers to wider adoption are less scientific than economic and cultural. Surveys by the European Association of Percutaneous Cardiovascular Interventions and the Japanese association CVIT documented persistent underuse outside East Asia, where imaging guidance in complex PCI has become routine. A white paper by Escané and colleagues catalogued the reasons: reimbursement gaps, longer procedure times, unfamiliarity with image interpretation, and organizational inertia. Health-economic analyses complicate the picture in imaging’s favor — the RENOVATE-COMPLEX-PCI cost-effectiveness analysis suggested that, despite upfront device costs, avoided repeat revascularizations and reduced infarctions can offset expenditures, particularly in complex anatomy where the event-rate reduction is largest.

The review also charts where the field is heading. Hybrid catheters combining IVUS and near-infrared spectroscopy can map lipid-rich, potentially vulnerable plaques, and the PROSPECT II natural-history study showed that such non-culprit lipid-rich plaques predict future events, opening the door to preventive local therapy. Computational advances promise to shrink the learning curve: artificial-intelligence algorithms now perform automated lumen and external elastic membrane contouring, stent-apposition analysis, calcium scoring, and even OCT-derived fractional flow reserve, validated in trials such as FLASH and FUSION. Combining optical flow ratio with post-stent physiology assessment may eventually let one imaging pull-through yield both anatomical and functional verdicts on the result, reducing contrast load and procedure time simultaneously.

For clinicians, the practical message distilled by Biccirè and colleagues can be organized around four questions: why, when, how and which. Why: because imaging converts an educated guess into measurement, and the randomized evidence shows this conversion lowers cardiac death, stent thrombosis and repeat procedures in the right patients. When: preferentially in left main, bifurcation, long, calcified and chronic total occlusion lesions, in acute coronary syndromes with ambiguous culprits, and in patients with diabetes or chronic kidney disease undergoing complex PCI. How: with disciplined pre-implantation sizing, deliberate post-dilatation, and verification against validated optimization thresholds, without compromising safety. Which: either OCT or IVUS produces comparable outcomes in most settings, so the choice can follow availability, operator expertise and specific needs — OCT’s superior resolution for bifurcation morphology and plaque characterization, IVUS’s deeper penetration for sizing large vessels such as the left main. What began as a technology searching for proof now stands, for complex interventions, on one of the firmer evidentiary foundations in interventional cardiology.

Subject of Research: Use of intracoronary imaging to guide percutaneous coronary intervention in randomized clinical trials

Article Title: Intracoronary imaging in percutaneous coronary intervention: why, when, how and which from large, randomized trials

Article References: Biccirè, F. G., Gonzalo, N., Hahn, J.-Y., Jang, I.-K., & Räber, L. (2026). Intracoronary imaging in percutaneous coronary intervention: why, when, how and which from large, randomized trials. Nature Reviews Cardiology. https://doi.org/10.1038/s41569-026-01342-3

Image Credits: AI Generated

DOI: 10.1038/s41569-026-01342-3

Keywords: intracoronary imaging, percutaneous coronary intervention, optical coherence tomography, intravascular ultrasound, stent optimization, randomized trials, bifurcation lesions, acute coronary syndrome, stent thrombosis, left main PCI, coronary artery disease, interventional cardiology