Systematic Review

Management of Coronary Artery Disease in the Context of Transcatheter Aortic Valve Implantation: A Systematic Review and Meta-analysis of Percutaneous Coronary Intervention Timing and an Algorithmic Approach to Management

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Abstract

Background: Transcatheter aortic valve implantation (TAVI) is widely performed for severe aortic stenosis (AS), often accompanied by coronary artery disease (CAD). The optimal management of CAD in TAVI patients remains uncertain. This study reviews the evidence on percutaneous coronary intervention (PCI) timing in TAVI, and proposes an algorithmic approach for CAD management. Methods: A comprehensive search of PubMed, EMBASE and Cochrane identified studies comparing PCI timing strategies in TAVI patients. Results: Thirteen studies with 15,412 participants were included. Mortality at 30 days (OR 5.70; 95% CI [1.34–24.36]) and 2 years (OR 4.40; 95% CI [2.60–7.44]) were significantly higher in the combined pre-TAVI and concomitant PCI group than in the post-TAVI cohort. Rates of other periprocedural complications, such as stroke and bleeding, varied across studies. Conclusion: There is no clear consensus on PCI timing in TAVI due to a lack of high-quality randomised data. An individualised, algorithmic approach is proposed for managing CAD in patients undergoing TAVI.

Keywords

Transcatheter aortic valve implantation, coronary artery disease, percutaneous coronary intervention, timing.,

Received:

Accepted:

Published online:

DOI: https://doi.org/10.15420/icr.2024.51

Disclosure: The authors have no conflicts of interest to declare.

Correspondence: Cian Murray, Cardiology Department, St James’s Hospital, James Street, Dublin 8, D08 NHY1, Ireland. E: murrac24@tcd.ie

Copyright:

© The Author(s). This work is open access and is licensed under CC-BY-NC 4.0. Users may copy, redistribute and make derivative works for non-commercial purposes, provided the original work is cited correctly.

Transcatheter aortic valve implantation (TAVI) is now a well-established treatment option for patients with severe aortic stenosis (AS), regardless of their surgical risk.1 Approximately 50–75% of these patients also have coronary artery disease (CAD) due to shared risk factors and underlying pathophysiological mechanisms.2,3 This coexistence poses challenges in managing both conditions simultaneously, and there is currently no consensus on the management of CAD in patients undergoing TAVI because the existing evidence primarily originates from non-randomised, observational studies.

In surgical aortic valve replacement (SAVR), concurrent CAD is typically treated with coronary artery bypass grafting (CABG), providing long-term mortality benefits without increasing operative mortality.4 For example, in 2022 the Society of Thoracic Surgeons reported that 42.6% of patients (12,543/29,416) who required SAVR also had CABG performed during the same procedure.5 Therefore, revascularisation prior to TAVI has been the traditional approach for significant coronary artery lesions. There is considerable debate about this approach, given that in patients without AS, revascularisation does not confer a mortality benefit in stable CAD.6,7 Nonetheless, the prevailing consensus has been to perform percutaneous coronary intervention (PCI) for significant left main stem and proximal left anterior descending artery (LAD) disease, despite limited supporting evidence. This raises the question of whether stable CAD patients undergoing TAVI should undergo revascularisation at all.6,7 Additionally, in patients undergoing TAVI there are uncertainties regarding the assessment of CAD severity, the clinical significance and prognosis of CAD and the optimal timing of PCI in those undergoing revascularisation.4,6–9

In relation to the timing of PCI, the current international guidelines provide a class 2a recommendation which cautiously suggests that PCI and TAVI may be performed as concomitant or staged procedures according to the clinical situation and the pattern of CAD.1,10 The modest strength of this evidence underscores the lack of a consensus opinion on the ideal timing of PCI in TAVI patients. TAVI candidates with severe CAD requiring revascularisation can undergo PCI as a separate procedure either before or after TAVI, or concomitantly during the TAVI procedure. Each timing strategy has distinct advantages and disadvantages based on factors such as patient characteristics, anatomical considerations (valve, aortic root and coronary anatomy) and the choice of TAVI valve.

Performing PCI before TAVI has been the conventional approach, due to concerns about accessing the coronary ostia after TAVI and the potential for ischaemic and haemodynamic complications during TAVI insertion. There is a growing body of research indicating that performing PCI concomitantly or post-TAVI is safe, feasible and potentially preferable. While there has been no randomised data published on this topic to date, there have been numerous high-quality observational studies published in recent years, especially focusing on PCI performed after TAVI insertion. There are also randomised controlled trials (RCTs) currently ongoing, including TAVI PCI, FAITAVI and COMPLETE TAVR. The aim of our systematic review and meta-analysis is to synthesise the latest research on the timing of PCI, evaluate the merits of each PCI timing strategy and propose a consensus based on current evidence. Furthermore, we sought to assess the current literature on the overall management of CAD in TAVI and synthesise this into a simplified algorithm that illustrates optimal management strategies based on the most up-to-date research.

Central Illustration: Suggested Algorithmic Approach to the Management of Coronary Artery Disease in Those Undergoing Transcatheter Aortic Valve Implantation

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In this review and proposed algorithm we have focused on patients who, following multidisciplinary team (MDT) discussion, are deemed to be more suitable for TAVI rather than SAVR. We have not specifically considered those undergoing SAVR with concomitant CAD, however, in the setting of significant CAD and severe AS in suitable patients, surgical intervention remains a viable treatment option and should be considered throughout the workup process.

Methods

Registration and Search Strategy

Our systematic search was aligned with the latest guidelines from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Our study’s design was registered in advance with PROSPERO (CRD42024520210). We carried out a comprehensive literature search across PubMed, EMBASE and the Cochrane Central Register of Controlled Trials, which was current as of February 2024. The search terms used included: percutaneous coronary intervention, transcatheter aortic valve implantation/replacement, timing and interval. The systematic search strategy with detailed search terms and PRISMA flow diagram are outlined in Supplementary Figure 1 and Supplementary Table 1.

Eligibility Criteria

Inclusion criteria:

  • Treatment of severe AS with TAVI.
  • Presence of concurrent CAD, and treatment that included PCI before, concomitant with or after TAVI.
  • A comparison of the timing of PCI relative to TAVI within one of the groups or between the groups.
  • Full text available, not a conference abstract.
  • Publication in English or a translation of such.

Study Selection, Data Extraction and Critical Appraisal

We created a bibliographic database with the aid of Mendeley, a reference management software. Article abstracts retrieved from our search were independently assessed by two reviewers (CM and CR) against the established inclusion criteria. Following the removal of duplicate articles, discrepancies in judgement about the relevance of articles were resolved via an open discussion with an independent third reviewer (HT). The full texts of the preliminarily selected articles were then thoroughly examined for compliance with our inclusion criteria. Additionally, we scrutinised the reference lists of these articles to identify any pertinent studies overlooked in the initial database search. Data extraction from the qualifying articles was independently carried out by two reviewers, using the PICO framework to guide information retrieval. To streamline the data extraction and storage process, we used the Cochrane Collaboration data extraction tool, Covidence.11

Risk of Bias

The evaluation of potential biases in the studies was conducted using the Newcastle–Ottawa Scale (NOS) for assessing the risk of bias in observational studies and the Cochrane Collaboration risk of bias tool for RCTs, with the findings organised in Supplementary Tables 2 and 3.12,13 The critical appraisal was completed by two reviewers independently (CM and CR), and in instances of differing assessments a third reviewer (HT) was consulted to resolve any discrepancies in opinion.

Statistical Analysis

Statistical analysis was conducted using RevMan (version 5.4.1). A random-effects model (DerSimonian and Laird [D+L]) was applied to account for variability in study design and patient populations, recognising the observational nature of the included studies.14 Heterogeneity was quantified using the I² statistic, accompanied by corresponding p values.15 Forest plots were used to visually present pooled effect size estimates, heterogeneity levels, and the weighted contribution of each study to the overall analysis. Effect sizes and statistical significance were reported using ORs with 95% CIs.

Algorithm

A suggested algorithm illustrating a stepwise approach to the management of CAD was subsequently developed based on a comprehensive analysis of the best available research.

Results

Search Results

The literature search yielded a total of 252 results. A grey search of the literature and citation search yielded four further results. Following the removal of 31 duplicates, 225 studies were screened by review of the abstracts. After the initial screening, 18 studies were selected for full text review. From these 18 full texts, a total of 13 studies met the inclusion criteria and were included in our analysis (Supplementary Figure 1).16–28

Methodological Characteristics, Quality of Studies, Patient Characteristics

The study pool consisted of 11 retrospective cohort studies, one prospective cohort study and one RCT totalling 15,412 participants who underwent both TAVI and PCI.16–28 Supplementary Table 4 summarises the methodological characteristics of the included studies. Of the total study population, 10,637 individuals (69.0%) received PCI before their TAVI, while 4,208 patients underwent PCI concurrent with their TAVI. A further 567 patients had PCI after completion of their TAVI procedure. The definitions of what constituted pre-TAVI, concomitant, and post-TAVI PCI varied across the studies and are listed in Supplementary Table 5. Study comparisons varied: six studies compared pre-TAVI with concurrent PCI timings and two assessed PCI before, during and after TAVI. Further studies contrasted pre- and post-TAVI PCI, concurrent versus post-TAVI and two different pre-TAVI timings. Procedural and baseline characteristics of the individual studies are listed in Supplementary Tables 5 and 6.

Main outcomes assessed in the included studies:

  • All-cause mortality: 30-day and at long-term follow up (24 months).16–28

  • Other periprocedural adverse events occurring after TAVI: predominantly standardised endpoints according to the Valve Academic Research Consortium (VARC)-2.29

    – Acute kidney injury (AKI): any severity.16–21,23–28

    – Major bleeding: classified as bleeding requiring transfusion, life-threatening bleeding or Bleeding Academic Research Consortium – stage 3 (BARC-3) criteria bleeding.16–21,23–28

    – Stroke: disabling and non-disabling.16–21,23–28

Table 1: Summary of Results

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Figure 1: Forest Plot of 30-day Mortality for Percutaneous Coronary Intervention: Pre-Transcatheter Aortic Valve Implantation versus Concomitant with Transcatheter Aortic Valve Implantation

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The key findings from the meta-analysis are presented below, with the results of individual studies detailed in Table 1.

Concomitant versus Pre-TAVI Percutaneous Coronary Intervention

Thirty-day Mortality

No significant difference in 30-day mortality was observed between the PCI before TAVI group and the PCI concomitant with TAVI group (OR 0.91; 95% CI [0.67–1.24]; Figure 1).16–21,23,25–28

Acute Kidney Injury

The rates of AKI incidence were highly variable among the PCI before TAVI group and the PCI concomitant with TAVI group (OR 0.90; 95% CI [0.51–1.60]; Supplementary Figure 2).16–21,23,25–28

Major Bleeding

No significant difference in major bleeding rates was observed between the PCI before TAVI group and the PCI concomitant with TAVI group (OR 0.80; 95% CI [0.52–1.24]; Supplementary Figure 3).16–21,23,25–28

Stroke

The incidence of stroke did not differ significantly between the PCI before TAVI group and the PCI concomitant with TAVI group (OR 1.16; 95% CI [0.96–1.42]; Supplementary Figure 4).16–21,23,25–28

Post-TAVI Percutaneous Coronary Intervention

Thirty-day Mortality

The combined concomitant and pre-TAVI group had significantly higher 30-day mortality rates compared with the PCI post-TAVI group, in the four studies that compared these cohorts (OR 5.70; 95% CI [1.34–24.36]; Figure 2).16,17,19,27

Figure 2: Forest Plot of 30-day Mortality for Percutaneous Coronary Intervention: Post-Transcatheter Aortic Valve Implantation versus Combined Concomitant and Pre-Transcatheter Aortic Valve Implantation

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Two-year Mortality

Three trials reported 2-year mortality data for a post-TAVI cohort.16,17,19 In those studies, the combined PCI concomitant and pre-TAVI groups had significantly higher 2-year mortality rates compared with the post-TAVI group (OR 4.40; 95% CI [2.60–7.44]; Figure 3).16,17,19

Figure 3: Forest Plot of 24-month Mortality for Percutaneous Coronary Intervention: Post-Transcatheter Aortic Valve Implantation versus Combined Concomitant and Pre-Transcatheter Aortic Valve Implantation

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Acute Kidney Injury

The rates of AKI incidence were significantly higher in the concomitant and pre-TAVI groups compared with the PCI post-TAVI group (OR 2.38; 95% CI [1.34–4.24]; Supplementary Figure 5).16,17,19,27

Major Bleeding

No significant difference in major bleeding rates was observed between the combined concomitant and pre-TAVI groups and the PCI post-TAVI group (OR 0.88; 95% CI [0.52–1.49]; Supplementary Figure 6).16,17,19,27

Stroke

The incidence of stroke did not differ significantly between the combined concomitant and pre-TAVI groups and the PCI post-TAVI group (OR 1.35; 95% CI [0.59–3.06]; Supplementary Figure 7).16,17,19,27

van Rosendael et al. exclusively examined different timing strategies within the pre-TAVI PCI group, comparing PCI performed within 30 days before TAVI to PCI performed more than 30 days before TAVI.24 Consequently, their study was not suitable for inclusion in the meta-analysis. Similarly, Kumar et al. compared a combined PCI concomitant with TAVI and post-TAVI group to a PCI pre-TAVI group.22 However, their study did not include a Kaplan–Meier analysis for mortality or report 30-day event rates, making it unsuitable for inclusion.

Discussion

The prevailing clinical practice for PCI timing in TAVI has been to perform PCI prior to the TAVI procedure. However, recent years have seen the emergence of both concomitant and post-TAVI PCI as viable revascularisation methods for CAD. The foundations for this shift began with single-centre, observational studies demonstrating the feasibility of post-TAVI PCI, which emerged in the mid-2010s.30 Once clinicians discovered the viability of accessing the coronary ostia after TAVI it became a more feasible timing strategy. A number of observational studies have been published comparing this method to concomitant and pre-TAVI PCI in recent years.16,17,19,27

Mortality

Our meta-analysis of trials assessing post-TAVI PCI demonstrated a significant reduction in 30-day and 2-year mortality rates in this cohort compared with the combined pre-TAVI and concomitant TAVI groups. In contrast, our meta-analysis of 10 trials comparing pre-TAVI PCI with concomitant PCI found no significant difference in mortality, either within individual trials or in the overall meta-analysis, despite variations in non-mortality outcomes. These findings highlight the potential of post-TAVI PCI as a promising timing strategy; however, they should be interpreted with caution due to the observational nature of the included studies and considerable variability in study design and patient populations. Additionally, these results emphasise the need for further large-scale, randomised studies to validate these outcomes and guide clinical practice.

Periprocedural Complications

Acute Kidney Injury

The reviewed studies show conflicting results on the incidence of AKI related to PCI timing in TAVI. The meta-analysis of four studies that included a post-TAVI PCI cohort showed a significantly lower rate of AKI compared with the combined pre-TAVI and concomitant groups. However, no significant difference in AKI rates was observed when comparing the pre-TAVI and concomitant groups. Earlier research, including a 2017 meta-analysis, linked concomitant PCI with higher AKI rates due to increased contrast load.31 This was supported by Rheude et al. and Fischer et al., who reported significantly higher AKI rates in patients undergoing simultaneous PCI and TAVI compared with staged procedures.19,20 These findings are a direct contradiction to those reported by Park et al., Tran et al. and Søndergaard et al., who observed higher AKI rates in staged PCI procedures.18,21,28 The discrepancy may stem from the observational nature of these studies, given that in the Tran et al. study the patients chosen for concomitant PCI had fewer comorbidities, a lower frequency of chronic kidney disease and were more likely to have single-vessel PCI performed.21 Although the Søndergaard et al. study was an RCT, it was also affected by selection bias because it randomised patients only to TAVI or SAVR and not to concomitant or staged PCI timing strategies and excluded those with high SYNTAX scores (>22).28 This trial found that patients who underwent concomitant procedures were given almost 100 ml less contrast dye on average compared with those in the staged group, suggesting that operators tend to be more conservative with contrast usage during PCI concomitant with TAVI. These variations underscore the necessity for RCTs to determine the definitive risk of AKI across different PCI timing strategies relative to TAVI.

Bleeding and Vascular Complications

This review and meta-analysis found no significant difference in bleeding rates between any of the groups. However, it is interesting to note the inconsistent findings regarding the incidence of vascular and bleeding complications. Despite previous studies linking PCI before TAVI to a heightened bleeding risk due to the necessity for dual antiplatelet therapy (DAPT), Kumar et al. noted a small but statistically significant increase in major vascular complications for concomitant or post-TAVI PCI.22,32,33 However, this difference disappeared after risk matching, indicating that clinical risk factors, not the timing of PCI, were the probable cause of the vascular complications seen during TAVI. Rheude et al. also reported elevated vascular complications and bleeding rates in the post-TAVI cohort.19 The apparent discrepancy in vascular complications is likely to be explained by the fact that 87.7% and 62.8% of patients in the concomitant and post-TAVI PCI groups, respectively, underwent PCI by femoral access, compared with 31.4% in the pre-TAVI cohort.

Conversely, Fischer et al. observed that simultaneous PCI and TAVI procedures led to more procedural blood loss than staged procedures, likely to be due to longer procedure times and increased heparin use.20 van Rosendael et al. noted that patients receiving PCI within 30 days prior to TAVI were at a higher risk for vascular injuries and minor bleeds compared with those who had a PCI at least 30 days before TAVI.24 Collectively, these findings imply that bleeding complications in this older patient demographic are multifactorial and not solely attributable to the requirement for DAPT.

Stroke

There were no significant differences in stroke rates between the combined concomitant and pre-TAVI groups and the PCI post-TAVI groups on meta-analysis (Supplementary Figure 7). Lunardi et al. reported a significantly higher incidence of in-hospital stroke in the pre-TAVI PCI group, in both the general and high-risk patient categories.16 Other studies did not report significant differences in stroke rates across timing strategies, although Rheude et al. did note a higher incidence of disabling strokes in the pre-TAVI and concomitant PCI groups, with the results approaching but not reaching statistical significance.19

Length of Stay and Overall Cost

Tran et al. reported that patients undergoing simultaneous PCI had significantly shorter post-TAVI and total hospital stays.21 Both Park et al. and Tran et al. reported significantly lower cumulative hospitalisation costs for concomitant PCI compared with staged procedures.18,21

Timing Strategy: Benefits and Drawbacks

Traditionally, PCI is performed before TAVI due to concerns about ischaemic and haemodynamic complications during TAVI, especially with significant coronary stenosis, and challenges in post-TAVI coronary access, particularly with supra-annular self-expanding valves. This practice is reflected in our review in that 69% of included patients received PCI prior to TAVI. There is currently a lack of definitive evidence to substantiate the concerns about ischaemic and haemodynamic complications during the TAVI procedure, which is reflected in the cautious level 2a evidence categorisation in the European guidelines.1 Performing PCI prior to TAVI may, however, be essential when dealing with acute coronary lesions that require timely intervention.

Concerns about coronary access after TAVI, especially with self-expanding, supra-annular valves, are valid, given that numerous studies have reported poor coronary access rates after valve insertion.34 Furthermore, as the use of TAVI expands to a lower risk, younger patient population, the probability of needing to re-access the coronary ostia in the case of acute coronary syndrome or progression of CAD is increased. However, more recent studies suggest that with the implementation of modified techniques, such as commissural alignment, and improved operator experience in addition to improved valve technology and design, PCI can be carried out successfully with self-expanding valves.35–38

Concomitant PCI with TAVI offers economic advantages by reducing total hospitalisation costs and the length of stay. It also eliminates the need for repeated use of contrast agent and limits vascular access to a single method. To date, no study has demonstrated a significant difference in mortality between this approach and pre-TAVI PCI.

Performing PCI after TAVI also has numerous theoretical advantages relative to other timing strategies. Successful treatment of AS alleviates left ventricular pressure overload, thereby enhancing cardiac output and systemic perfusion. These positive haemodynamic changes could lead to fewer complications during PCI, including renal or cerebral ischaemia, which may explain the reduced stroke rate seen in the post-TAVI PCI cohort in the Lunardi et al. study.16 This is particularly relevant for complex interventions, such as those addressing chronic total occlusions or calcium modification techniques, which pose a higher risk of hypotension and other complications, particularly given that coronary calcification is more prevalent in older populations. Furthermore, addressing the aortic valve obstruction before conducting PCI enables a more precise evaluation of the lesion’s ischaemic risk, using physiological indices such as fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR), particularly in asymptomatic patients. This approach could enable patients to forego unnecessary PCI procedures.

Management of Coronary Artery Disease in the Context of TAVI

Requirement for Revascularisation

The role of PCI in patients with CAD undergoing TAVI remains a subject of considerable debate. For those eligible for surgery, SAVR with concomitant CABG has long been the gold standard for managing significant CAD, offering proven mortality benefits and avoiding the risks of a future redo sternotomy.4 This is now coming into question, however, with the publication of the recent TCW trial, the first RCT to compare PCI with TAVI to combined SAVR and CABG in patients with severe AS and comorbid CAD, which reported favourable mortality outcomes with the percutaneous approach.39 Regardless of these findings, significant uncertainty persists in those chosen for TAVI regarding the necessity of coronary revascularisation. In patients with stable CAD and no severe AS, evidence suggests that PCI does not provide a mortality advantage over optimal medical therapy.6,7,40 Nevertheless, clinical practice often leans toward PCI for significant left main stem or proximal LAD disease, despite the lack of robust supporting evidence. Historically, the consensus was to perform PCI for significant CAD in TAVI patients, reflecting the approach in SAVR and CABG. However, this practice is now increasingly being questioned.

A meta-analysis by Aarts et al., which included 13 observational studies and one RCT, found no significant variation in clinical outcomes in TAVI patients with severe CAD who underwent PCI versus those who did not at both short- and long-term follow-up.39 This is in contrast to the results of the recently published NOTION-3 trial.41 This was an RCT comparing PCI with conservative treatment, in patients with at least one coronary artery stenosis with an FFR of ≤0.80 or a diameter stenosis of at least 90%. They reported a significantly lower composite risk of death, MI and urgent revascularisation at 2-year follow-up with the PCI group. This outcome was driven by a reduction in MI and revascularisation, and no mortality benefit was demonstrated. Timing of PCI in relation to TAVI was also not fully assessed, with 74% of patients undergoing the procedure before TAVI versus 26% who had PCI performed during or within 2 days after the procedure.41 Furthermore, there was no benefit demonstrated in those aged ≥82 years. Consequently, uncertainty remains regarding the necessity for PCI in these patients, but the results of ongoing RCTs, such as COMPLETE TAVR, TAVI PCI and FAITAVI, are awaited in the hope that they will provide further clarity on this issue.

Patient-specific Factors

Individual patient factors should also guide the decision for revascularisation. PCI is generally performed in those with a clinical presentation with angina, however, given the overlap of symptoms with severe AS, it can be challenging to clearly differentiate angina caused by CAD. A strategy of performing the TAVI first and then reassessing symptoms may be reasonable. Furthermore, in elderly or frail patients or in those with pre-morbid conditions such as chronic kidney disease (CKD), clinicians are likely to favour a single procedure to prevent periprocedural complications in this high-risk patient cohort. TAVI has a clear mortality benefit, whereas PCI in stable CAD does not, therefore treating AS in the first instance seems preferable. Coronary lesion location may also influence revascularisation strategy given that an increased mortality rate has been reported, associated only with proximal LAD lesions.42 There are, however, no robust randomised data to guide decision-making in relation to patient-specific factors.

Assessment of Coronary Artery Disease

The assessment of CAD in patients with severe AS is also an area of considerable debate. Traditionally, invasive coronary angiography has been used for accurate disease evaluation, as recommended by international guidelines.1,10 However, non-invasive CT coronary angiography (CTCA) combined with CT TAVI, which is standard for procedural planning, is an appealing alternative, reducing costs and risks such as AKI and vascular complications associated with invasive angiography. Although many patients still undergo invasive angiography due to significant levels of severe CAD and coronary calcification in severe AS limiting CT evaluation, it may be possible to reduce the number of invasive angiographies in this high-risk patient cohort by up to 37%.43

Invasive angiography also enables physiological assessment of coronary lesions, however, severe AS is known to affect indices such as FFR, due to the increased left ventricular (LV) mass and pressure causing a blunted hyperaemic response, leading to the underestimation of lesion severity.44 Furthermore, the effect of adenosine in FFR may be blunted in severe AS patients.45 iFR, which is independent of systole and the requirement of adenosine, is a promising alternative but lacks robust outcome data for TAVI patients.44 FFR-CT is a recent advancement that combines computational fluid dynamics with standard CTCA to simulate invasive FFR, enabling anatomical and functional assessments without the need for invasive angiography, offering a faster and cost-effective alternative.46,47 Although preliminary data are promising there are currently no randomised data supporting its use in severe AS.48

Valve Selection

The selection of transcatheter heart valve (THV) also plays a significant role in the management of CAD in TAVI patients. As TAVI is used more frequently in younger, lower-risk patients, the ensuring of future coronary access becomes increasingly important. Factors influencing THV selection have traditionally included anatomical suitability, availability and operator expertise. However, long-term considerations including valve durability, maintaining coronary access, and the feasibility of future TAVI-in-TAVI procedures are now equally relevant. As previously mentioned, supra-annular leaflets in some self-expanding valves can hinder coronary cannulation, whereas valves with lower stent frame height and intra-annular leaflets, facilitate easier access. Techniques, such as the implementation of commissural alignment, and developments in valve technology have been shown to improve the rates of post-TAVI coronary access.49 Given that younger patients are now expected to outlive their TAVI valves, the demand for TAVI-in-TAVI procedures is anticipated to increase. This approach can lead to displacement of the original bioprosthetic leaflets, overlapping stent frames, and potential impairment of both coronary flow and future coronary cannulation.50 Coronary access impairment following TAVI-in-TAVI depends on factors such as the coronary take-off height relative to the neoskirt and the distance between the THV stent frame and the aortic wall above the coronary ostia.51 Consequently, the choice of THV is crucial, given that valves with shorter frame heights are likely to facilitate easier coronary access. Additionally, commissural alignment techniques should be routinely used to optimise coronary access in these patients.

Algorithm

It is hoped that numerous RCTs currently underway will provide further insights into these complex clinical decisions. Until more robust data are available to guide decision-making, we must rely on the best available observational data. We propose a suggested algorithm for the management of CAD in patients undergoing TAVI based on the current available evidence and expert opinion. This does not apply to those being considered for SAVR because this cohort should all have full assessment of coronary anatomy by invasive angiography.

Limitations and Future Studies

This systematic review and meta-analysis has several important limitations, largely owing to the observational nature of the studies, which inherently leads to selection bias. The timing of PCI in relation to TAVI, patient eligibility for TAVI, and the procedural strategies used were left to the discretion of the operators, resulting in variability based on centre preferences and the clinical condition of the patients.17 This is likely to explain the variability seen in the rates of procedural complications between the studies. Many studies also lacked a clear definition of CAD severity and did not specify whether high-risk PCI was performed, potentially introducing bias into the reported outcomes and complication rates. Additionally, fluoroscopy exposure between the groups was not assessed, representing a potential area for future research. Finally, due to small sample sizes in the post-TAVI PCI cohort, some of the studies may have been underpowered to accurately report the outcomes studied.

Further research should also aim to further elucidate the ideal timing within each strategy. For example, research has yet to explore the question of whether concomitant PCI is optimally performed immediately before or immediately after TAVI, or whether post-TAVI PCI should be performed during the same hospital stay or as a staged procedure during a separate admission. These limitations underscore the need for high-quality RCTs to clarify the best PCI timing strategy, as well as to address other key aspects of CAD management in AS, such as CAD assessment, the need for revascularisation, and valve selection.

Conclusion

There is currently no definitive consensus in the literature regarding the necessity of PCI for patients undergoing TAVI, nor the optimal timing if PCI is required. The best strategy for each patient should be tailored to the individual risk profile, symptoms and clinical presentation, the anatomical and procedural specifics, valve choice and the expertise of the treating centre.

This review highlights a critical gap in high-quality randomised data and emphasises the persistent uncertainty in clinical practice due to the current reliance on non-randomised, observational studies. If required, post-TAVI PCI has shown promise as the only strategy to yield a significant mortality benefit compared with other timing strategies. Ongoing RCTs and future research will be pivotal in the development of a more definitive clinical guideline for the optimal timing of PCI as well as for the comprehensive management of CAD in the context of TAVI.

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