Clinical Outcomes of Combined TAVR-PCI Versus SAVR-CABG in Patients with Aortic Stenosis and Coronary Artery Disease: A Systematic Review and Meta-Analysis

Background/Objectives: Coronary artery disease coexists with severe aortic stenosis in about half of patients. Surgical aortic valve replacement with coronary artery bypass grafting (SAVR+CABG) is guideline-recommended, but transcatheter aortic valve replacement with percutaneous coronary intervention (TAVR+PCI) is increasingly used. Prior meta-analyses double-counted overlapping populations and did not report randomized evidence separately; we re-examined the comparison after correcting both. Methods: PubMed, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science and ClinicalTrials.gov were searched up to July 2026 for randomized and comparative observational studies, excluding reports with overlapping populations. Outcomes were pooled with random-effects models, stratified by study design, and re-analysed without administrative databases. Certainty was rated with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Results: Fourteen studies were included (two randomized trials, nine cohorts, three administrative databases), comprising 154,892 patients (28,569 TAVR+PCI; 126,323 SAVR+CABG). TAVR+PCI was associated with lower early mortality (odds ratio (OR) 0.60, 95% confidence interval (CI) 0.44–0.84) and less acute kidney injury (OR 0.34, 0.20–0.57), but greater pacemaker implantation (OR 2.18, 1.93–2.46) and major vascular complications (OR 3.38, 1.65–6.89). Stroke, myocardial infarction and one-year mortality (OR 0.80, 0.58–1.10) did not differ; bleeding results were inconsistent (I2 = 95%). Over 12–72 months, mortality was higher with TAVR+PCI (hazard ratio (HR) 1.38, 1.28–1.49; nine observational studies), unchanged without the largest cohort. Administrative databases drove heterogeneity but not the direction of any early outcome. Certainty was moderate for pacemaker implantation and low or very low otherwise; randomized data were too limited to confirm these findings. Conclusions: In predominantly observational evidence, TAVR+PCI was associated with lower early risk but higher mortality over longer follow-up. This trade-off supports individualized Heart Team decisions rather than the superiority of either strategy. Adequately powered randomized trials with long-term follow-up are needed.