Three late-breaking trials presented at ESC Congress 2026 offer new insights into the management of structural heart disease and heart failure (HF), spanning coronary revascularization during TAVI, transcatheter treatment of tricuspid regurgitation, and post-TAVI antithrombotic therapy. Together, the TAVI PCI, ACASA-TAVI and TRIC-I-HF studies provide important evidence to help refine treatment strategies and improve patient outcomes.

TAVI PCI Trial
In TAVI PCI, which was simultaneously published in NEJM, a strategy of TAVI before PCI was noninferior to a PCI-first strategy in patients with severe aortic stenosis and concomitant coronary artery disease, suggesting the ability to develop treatment strategies based on individual patients.

Patients were randomly assigned to receive TAVI before PCI or PCI before TAVI. The primary endpoint was a composite of death from any cause, nonfatal myocardial infarction, ischemia-driven revascularization, life-threatening, disabling, or major bleeding, and rehospitalization related to the valve, procedure or HF at one year.

At one year, a primary endpoint event occurred in 105 patients (22.2%) in the TAVI-first group and in 112 patients (24.2%) in the PCI-first group. Serious adverse events occurred in 264 patients in the TAVI-first group compared with 273 patients in the PCI-first group. There was no evidence of treatment heterogeneity across prespecified subgroups, such as age, sex and complexity of PCI.

“An interesting observation was that fewer patients in the TAVI-first group ultimately underwent PCI,” said Barbara Elisabeth Stähli, MD, who presented the findings. “Importantly, this was not because coronary access was impaired after TAVI. Rather, once the valve had been treated, the clinical decision about whether PCI was still necessary sometimes changed.”

ACASA-TAVI Trial
The ACASA-TAVI trial, simultaneously published in JAMA, also addressed TAVI, enrolling 360 patients between the ages of 65 and years who were undergoing the procedure for sever aortic stenosis. Researchers found that a 12-month non-vitamin K antagonist oral anticoagulant (NOAC) monotherapy strategy following TAVI reduced the incidence of hypoattenuated leaflet thickening (HALT) compared with an acetylsalicylic acid (ASA) monotherapy strategy. Additionally, NOAC monotherapy was noninferior for bleeding, thromboembolic events, or death compared with ASA monotherapy.

“Clinicians may perceive the bleeding risk of anticoagulants to be higher than that of antiplatelet agents, but we found in this study that life-threatening and lethal bleeding occurred only in patients in the ASA group,” said “Øyvind Lie, MD, PhD, from Oslo University Hospital in Norway. “We were able to show substantial reductions in signs of subclinical leaflet thrombosis with NOAC monotherapy, without compromising safety. Results from the ACASA-TAVI trial may establish a new antithrombotic treatment paradigm after TAVI and could be used to inform future guidelines.”

TRIC-I-HF Trial
Transcatheter tricuspid-valve repair was the focus of the TRIC-I-HF trial, also simultaneously published in NEJM, with researchers comparing tricuspid valve repair plus medical therapy with medical therapy alone in 360 patients with symptomatic severe tricuspid regurgitation and an increased risk of future HF events. The mean age of participants was 80 years and roughly 56% were women.

Researchers found transcatheter tricuspid-valve repair plus medical therapy was superior to medical therapy alone with respect to a hierarchical composite of death from any cause, hospitalization for HF, and quality-of-life improvement at one year. They also found that tricuspid valve repair was associated with a lower risk of a composite of death from any cause or hospitalization for HF through three years.

“Among these high-risk patients, transcatheter tricuspid valve repair on top of medical therapy resulted not only in quality-of-life improvements but also in meaningful and sustained reductions in hard clinical outcomes, which has not been demonstrated before with the intervention, said Jörg Hausleiter, MD, et al.

Visit ACC’s ESC Congress 2026 coverage page to explore the latest science and key takeaways shaping cardiovascular care.


Clinical Topics:
Anticoagulation Management, Cardiac Surgery, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and VHD, Interventions and Structural Heart Disease


Keywords:
ESC Congress, ESC26, Transcatheter Aortic Valve Replacement, Protamines, Aortic Valve Stenosis, Antithrombotic Therapy, Platelet Aggregation Inhibitors, Anticoagulants, Thrombosis, Heart Valve Prosthesis