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Timing of PCI in Patients Undergoing Transcatheter Aortic-Valve Implantation
Key result
TAVI followed by PCI is noninferior to PCI followed by TAVI for 1-year major events.
- risk difference -2.0 percentage points
- 95% CI -7.4 to 3.4
- P<0.001 for noninferiority
- n=986
Why the trial?
Many patients undergoing TAVI have concomitant coronary artery disease, yet whether PCI should be performed before or after the valve procedure had never been randomised, leaving the sequencing decision to local practice.
Does a strategy of TAVI before PCI reduce adverse clinical events in patients with severe aortic stenosis and coronary artery disease compared to PCI before TAVI?
Population
986 patients with severe aortic stenosis and coronary artery disease
Comparison
TAVI-first vs PCI-first treatment sequence
Design
International, open-label, randomized noninferiority trial (48 European centres)
Follow-up
1 year
Authors
Discussion
Key questions
No takes yet. Share an insight, caveat, or question.
Where experts stand
Experts read TAVI PCI as confirmatory rather than practice-changing, agreeing that a TAVI-first approach is a safe option but noting the trial's low-complexity coronary disease limits broader conclusions.
Cardiologists broadly accept the noninferiority finding, viewing it as evidence that clinicians can safely do the valve first when both TAVI and PCI are planned. Several voices note the trial validates what many centers already do in practice. The live question is whether TAVI-first holds up in patients with more complex coronary anatomy than the low-risk population studied here.
Agreement
Multiple clinicians agree that TAVI-first is a viable sequencing option, supported by the noninferiority result, though they caution this is not proof of superiority over PCI-first.
3 clinicians say this directly
2 takes classified by contention axis so far — the map appears as more land.
Still unclear
Experts flag that the trial enrolled patients with low coronary complexity (median SYNTAX score of 10) and used predominantly balloon-expandable valves, leaving open whether TAVI-first is equally safe in complex multivessel disease or with self-expanding valves. It also remains unclear whether PCI can be deferred entirely after TAVI rather than simply delayed, given that PCI was omitted more often in the TAVI-first arm.
Key expert perspectives
PCI should follow TAVI only when clinically indicated, not as routine upfront strategy
Garzon sees the noninferiority result as supporting a selective approach: do TAVI first and reserve PCI for cases where it is clinically needed afterward, rather than stenting every patient before the valve procedure.
Distilled from their postX post
MGMartha GulatiCardiologistPractice takeBefore results
Evidence is catching up to what clinicians already do in practice
Gulati previewed the hot line session and remarked that the evidence on PCI timing relative to TAVI is catching up to existing clinical practice.
Distilled from their postX post
Heerajnarain BulluckInterventional / Structural Cardiology · Leeds General Infirmary, Leeds Teaching Hospitals NHS TrustResults readoutAug 30Sequence of TAVI and PCI does not matter for outcomes at one year
Bulluck frames the trial as answering a practical planning question for patients needing both procedures, highlighting that sequencing had no meaningful impact on major clinical events.
Distilled from their postX post
Implication
PCI timing in TAVR patients with CAD remains unresolved; leaves open whether omitting routine pre-TAVR PCI is safe.
Key Points
- To evaluate whether performing transcatheter aortic-valve implantation (TAVI) before percutaneous coronary intervention (PCI) is noninferior to performing PCI before TAVI in patients with severe aortic stenosis and coronary artery disease.
- International, open-label, randomized noninferiority trial conducted across 48 centers in Europe (N=986; NCT04310046).
- Participants were randomly assigned in a 1:1 ratio to receive either TAVI before PCI (TAVI-first group, n=498) or PCI before TAVI (PCI-first group, n=488).
- The primary end point was a 1-year composite of all-cause mortality, nonfatal myocardial infarction, ischemia-driven revascularization, rehospitalization related to the valve, procedure, or heart failure, or major/disabling/life-threatening bleeding (noninferiority margin: 6.6 percentage points).
- A primary end-point event occurred in 105 patients (22.2%) in the TAVI-first group and 112 patients (24.2%) in the PCI-first group (risk difference, −2.0 percentage points; 95% CI, −7.4 to 3.4; P<0.001 for noninferiority).
- Serious adverse events were reported in 264 patients in the TAVI-first group and in 273 patients in the PCI-first group.
Evidence details
What drove the result?
| Outcome | TAVI first | PCI first |
|---|---|---|
| Death, MI, revascularization, rehospitalization, or major bleeding | 105 (22.2%) | 112 (24.2%) |
| Primary composite · RD −2.0 pp (95% CI −7.4 to 3.4); noninferior (margin 6.6 pp; p<0.001) | ||
Limitations & tradeoffs
Safety
Serious adverse events occurred in 264 vs 273 patients (of 498 vs 488 randomized).
Design limitations
The trial was open-label, and individual components of the composite are not reported in the abstract.
Statistical certainty
Noninferiority was defined against a wide 6.6-percentage-point margin, and reported percentages do not match crude counts over the randomized Ns, implying an analysis population not detailed in the abstract.
Structured PICO
Does a strategy of TAVI before PCI reduce adverse clinical events in patients with severe aortic stenosis and coronary artery disease compared to PCI before TAVI?
P
Population
986 patients with severe aortic stenosis and coronary artery disease followed for 1 year.
I
Intervention
Transcatheter aortic-valve implantation (TAVI) performed before percutaneous coronary intervention (PCI) (TAVI-first strategy)
C
Comparator
Percutaneous coronary intervention (PCI) performed before TAVI (PCI-first strategy)
O
Outcome
Composite of death from any cause; nonfatal myocardial infarction; ischemia-driven revascularization; rehospitalization related to the valve, procedure, or heart failure; or life-threatening, disabling, or major bleeding at 1 year after randomizationcomposite
Main Result
Effect estimate: risk difference -2.0 percentage points (95% CI -7.4 to 3.4)
Absolute Event Rate: 22.2% vs 24.2%
Absolute Risk Reduction: 2%
p-value: p=<0.001 for noninferiority
In patients with severe aortic stenosis and concomitant coronary artery disease, a strategy of performing TAVI before PCI is noninferior to PCI before TAVI regarding a 1-year composite clinical endpoint.
Coverage & sources
Journal, society, and media accounts. Useful signal, not independent expert judgment.
Cite This Study
Stähli et al. (2026) conducted an RCT in Severe aortic stenosis and coronary artery disease (n=986). TAVI before PCI (TAVI-first) vs. PCI before TAVI (PCI-first) was evaluated on Composite of death from any cause; nonfatal myocardial infarction; ischemia-driven revascularization; rehospitalization related to the valve, procedure, or heart failure; or life-threatening, disabling, or major bleeding at 1 year (risk difference -2.0 percentage points, 95% CI -7.4 to 3.4, p=<0.001 for noninferiority). TAVI before PCI was noninferior to PCI before TAVI for the primary composite endpoint at 1 year (22.2% vs 24.2%; risk difference -2.0 percentage points; P<0.001 for noninferiority).