Aortic stenosis and coronary artery disease: which should be treated first?

In this review, Henryk Dreger explores the complex interplay between aortic stenosis and coronary artery disease, highlighting the latest evidence on PCI timing and its implications for clinical decision-making.

Aortic stenosis and coronary artery disease: prevalence and clinical challenge

Approximately half of all patients with severe aortic stenosis (AS) have concomitant coronary artery disease (CAD)¹. As assessment of coronary anatomy by either computed tomography (CT) or invasive angiography is part of the routine diagnostic work-up in most patients with AS, the management of newly detected coronary lesions represents a frequent point of discussion within multidisciplinary heart teams.

PCI before or after TAVI: what do recent trials tell us?

Three recently published randomised trials have addressed the management of CAD in the context of AS. First, the TCW trial compared a fully percutaneous strategy (fractional flow reserve [FFR]-guided percutaneous coronary intervention [PCI] followed by transcatheter aortic valve implantation [TAVI]) with combined surgical aortic valve replacement (SAVR) and coronary artery bypass grafting (CABG) in 172 patients.
The primary composite endpoint of all-cause mortality, myocardial infarction, disabling stroke, clinically driven target-vessel revascularisation, valve reintervention, and life-threatening or disabling bleeding at 1 year was significantly lower in the percutaneous group (hazard ratio [HR] 0.17, 95% CI 0.06-0.51). This difference was primarily driven by lower all-cause mortality (0% vs. 10%, p=0.0025) and fewer life-threatening bleeding events (2% vs. 12%, p=0.010)². In addition, two contemporary randomised trials have provided additional insights specifically into PCI in patients undergoing TAVI.
NOTION-3 randomised 455 patients with aortic stenosis and physiologically significant coronary lesions (FFR ≤0.80 or ≥90% stenosis) to either PCI followed by TAVI or TAVI alone. PCI reduced the composite of death, myocardial infarction, or urgent revascularisation at a median follow-up of 2 years (HR 0.71, 95% CI 0.51-0.99), albeit at the cost of increased bleeding (HR 1.51, 95% CI 1.03 to 2.22)³.
The PRO-TAVI trial enrolled 466 patients and demonstrated that a strategy of deferring PCI was non-inferior to routine PCI before TAVI at one year for a broader composite endpoint that also included major bleeding (HR 0.89, 95% CI 0.62-1.28, p=0.0008 for non-inferiority), with a clear reduction in bleeding complications in the deferral group (HR 0.39, 95% CI 0.21 to 0.73)⁴. Taken together, these trials suggest a trade-off between fewer ischemia-driven events and more bleeding with routine PCI before TAVI.

An argument for routinely performing PCI before TAVI has been the concern about ischemia-driven complications during the procedure. In line with the randomised data, however, a retrospective analysis of 1,911 TAVI patients – 25% of whom had untreated CAD – reported no difference in periprocedural ischemia-driven complications between patients with and without obstructive CAD. This was observed even in patients with triple-vessel disease and ≥70% left main stenosis⁵, suggesting that untreated CAD does not necessarily translate into excess procedural risk during TAVI. Consistently, a contemporary nationwide analysis found no reduction in mortality, myocardial infarction, or urgent revascularisation with PCI before TAVI, but a significantly higher risk of bleeding, further questioning a routine preprocedural revascularisation strategy⁶.

Optimising treatment strategy: timing of PCI and individualised decision-making

This raises the question of whether deferring PCI until after TAVI can preserve the benefits of revascularisation while reducing bleeding risk. While randomised data are currently lacking, this strategy is being evaluated in ongoing trials (e.g., TAVI-PCI)⁷. Observational data provide some support: in the REVASC-TAVI registry, including 1,603 patients, all-cause mortality was significantly lower in patients undergoing PCI after TAVI compared with PCI before or concomitant with TAVI (6.8% vs. 20.1% vs. 20.6%; p<0.001). Similarly, the composite of death, stroke, myocardial infarction, or rehospitalisation for heart failure was reduced in the post-TAVI PCI group (17.4% vs. 30.4% vs. 30.0%; p=0.003)⁸.

In summary, no randomised controlled trial to date has directly addressed the optimal timing of PCI in patients undergoing TAVI. Available evidence suggests that revascularisation reduces ischemic events during mid- to long-term follow-up, whereas PCI performed before TAVI increases periprocedural bleeding risk without clearly improving short-term outcomes. Deferral of PCI does not appear to increase ischemia-related complications during TAVI, and emerging observational data suggest a potential advantage of performing PCI after TAVI.

However, timing decisions cannot be generalised. In specific anatomical scenarios – such as small annuli requiring implantation of self-expanding valves with supra-annular leaflets – coronary access after TAVI may be challenging, and PCI before TAVI may therefore be preferable. Ultimately, treatment strategies should be individualised, balancing ischemic and bleeding risks while carefully considering aortic root and coronary anatomy, optimal valve choice, and lifetime management.

References

Tarantini G, Tang G, Nai Fovino L, Blackman D, Van Mieghem NM, Kim WK, et al. Management of coronary artery disease in patients undergoing transcatheter aortic valve implantation. A clinical consensus statement from the European Association of Percutaneous Cardiovascular Interventions in collaboration with the ESC Working Group on Cardiovascular Surgery. EuroIntervention. 2023 May;19(1):37–52. doi:10.4244/EIJ-D-22-00958
Kedhi E, Hermanides RS, Dambrink JHE, Singh SK, Ten Berg JM, Van Ginkel D, et al. TransCatheter aortic valve implantation and fractional flow reserve-guided percutaneous coronary intervention versus conventional surgical aortic valve replacement and coronary bypass grafting for treatment of patients with aortic valve stenosis and complex or multivessel coronary disease (TCW): an international, multicentre, prospective, open-label, non-inferiority, randomised controlled trial. The Lancet. 2024 Dec;404(10471):2593–602. doi:10.1016/S0140-6736(24)02100-7
Lønborg J, Jabbari R, Sabbah M, Veien KT, Niemelä M, Freeman P, et al. PCI in Patients Undergoing Transcatheter Aortic-Valve Implantation. N Engl J Med. 2024 Dec 12;391(23):2189–200. doi:10.1056/NEJMoa2401513
Delewi R, Aarts HM, Broeze GM, Hemelrijk KI, Van Ginkel DJ, Versteeg GAA, et al. Deferral of percutaneous coronary intervention in patients undergoing transcatheter aortic valve implantation (PRO-TAVI): an investigator-initiated, multicentre, open-label, non-inferiority, randomised controlled trial. The Lancet. 2026 Mar;S0140673626003089. doi:10.1016/S0140-6736(26)00308-9
Persits I, Layoun H, Kondoleon NP, Spilias N, Badwan O, Sipko J, et al. Impact of untreated chronic obstructive coronary artery disease on outcomes after transcatheter aortic valve replacement. Eur Heart J. 2024 Jun 1;45(21):1890–900. doi:10.1093/eurheartj/ehae019
Louca A, Petursson P, Sundström J, Hagström H, Rück A, James S, et al. PCI Versus Conservative Management Before TAVR in Patients With Significant Coronary Artery Disease: A Nationwide Instrumental Variable Analysis. Circ Cardiovasc Interv. 2026 Apr;19(4). doi:10.1161/CIRCINTERVENTIONS.125.016337
Stähli BE, Linke A, Westermann D, Van Mieghem NM, Leistner DM, Massberg S, et al. A randomized comparison of the treatment sequence of percutaneous coronary intervention and transcatheter aortic valve implantation: Rationale and design of the TAVI PCI trial. Am Heart J. 2024 Nov;277:104–13. doi:10.1016/j.ahj.2024.07.019
Rheude T, Costa G, Ribichini FL, Pilgrim T, Amat Santos IJ, De Backer O, et al. Comparison of different percutaneous revascularisation timing strategies in patients undergoing transcatheter aortic valve implantation. EuroIntervention. 2023 Sep;19(7):589–99. doi:10.4244/EIJ-D-23-00186

The Essentials - TAVI

Author

Henryk Dreger

@HenrykDreger

Interventional cardiologist / Cardiologist

Berlin, Germany

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