Routine Versus Deferred Percutaneous Coronary Intervention in Patients Undergoing Transcatheter Aortic Valve Replacement: A Meta-Analysis With Reconstructed Individual Patient Data

Background The optimal management of concomitant coronary artery disease in patients undergoing transcatheter aortic valve replacement (TAVR) remains controversial. Whether routine percutaneous coronary intervention (PCI) before TAVR provides clinical benefit compared to a strategy of deferral is unclear. Methods We performed a meta-analysis of randomized controlled trials (RCT) comparing routine PCI before TAVR with a strategy of PCI deferral. The primary end points were a composite of major adverse cardiovascular and cerebrovascular events (MACCE) and all-cause mortality. Secondary end points included myocardial infarction, stroke, revascularization, and major bleeding. We applied a random-effects model to calculate hazard ratios (HR) and 95% confidence intervals (CI). We also performed a pooled time-to-event analysis using reconstructed individual patient data. Results We included 3 RCT (ACTIVATION, NOTION-3, and PRO-TAVI) comprising a total of 1156 patients. The pooled cohort had a median age exceeding 81 years and exhibited low anatomic coronary complexity (median Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery scores ≤10). Routine PCI did not significantly reduce the risk of MACCE (HR, 0.84; 95% CI, 0.62-1.13; P = .25) or all-cause mortality (HR, 0.88; 95% CI, 0.67-1.17; P = .38). Pooled Kaplan-Meier analysis confirmed no difference in all-cause mortality over 48 months (HR, 0.89; 95% CI, 0.68-1.17; P = .41). Although routine PCI was associated with a significant reduction in any revascularization (HR, 0.24; 95% CI, 0.06-0.89; P = .03) and urgent revascularization (HR, 0.33; 95% CI, 0.12-0.87; P = .02), it was associated with increased bleeding events (HR, 1.96; 95% CI, 1.28-3.00; P < .01). No significant differences were observed regarding myocardial infarction or stroke. Conclusions Routine PCI before TAVR did not reduce mortality or MACCE compared to a deferral strategy. Although routine PCI lowered the risk of subsequent urgent revascularization, it significantly increased the risk of major bleeding.