Impact of Extent of Coronary Artery Disease in Transcatheter Aortic Valve Replacement

Q: What is the clinical evidence from this study?

Study design: RCT. Population: Concomitant coronary artery disease in patients undergoing TAVR (n=466). Intervention: Deferral of percutaneous coronary intervention (PCI) vs. PCI before TAVR. Primary outcome: Composite of all-cause mortality, myocardial infarction, stroke, and major bleeding at 1 year.

Q: What does this research mean for the field?

In patients undergoing TAVR with concomitant coronary artery disease, deferral of PCI reduces bleeding risk overall but increases the risk of composite ischemic events in those with complex coronary disease (SYNTAX score >17). Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Gijs M. Broeze; Hugo Marc Aarts; Johanna da Silva Voorham; Kimberley Iris Hemelrijk; Dirk Jan van Ginkel; Geert A. A. Versteeg; Maik J. Grundeken; Bimmer E.P.M. Claessen; Pim A.L. Tonino; Carl E. Schotborgh; Martijn Meuwissen; Gert K. van Houwelingen; Joanna J. Wykrzykowska; Giovanni Amoroso; Tessel N. E. Vossenberg; Pieter A. Vriesendorp; Niels van Royen; Jurriën M. ten Berg; Jan G.P. Tijssen; Michiel Voskuil; Ronak Delewi

doi:10.1016/j.jcin.2026.07.034

Key result

Deferring PCI before TAVR in complex CAD brings ~2.4-fold higher risk for major events.

n=466

Graphical abstract published by JACC: Cardiovascular Interventions — Graphical abstract · Published by JACC: Cardiovascular Interventions · CC BY 4.0

Why the study?

The association between extent of coronary artery disease quantified by SYNTAX score and clinical outcomes in patients undergoing TAVR was unclear.

Does deferral of percutaneous coronary intervention compared to PCI before TAVR impact outcomes in patients with significant coronary artery disease based on their SYNTAX score?

Key Points

To assess the relationship between coronary artery disease complexity, measured by the SYNTAX score, and 1-year clinical outcomes in patients undergoing transcatheter aortic valve replacement randomized to receive or defer percutaneous coronary intervention.
Substudy of the randomized controlled PRO-TAVI trial (NCT05078619) evaluating 466 patients with significant coronary artery disease undergoing TAVR.
Participants were randomized to either pre-TAVR percutaneous coronary intervention (PCI) or deferral of PCI, with baseline SYNTAX score calculated from preprocedural angiograms and stratified by quartiles.
Assessed a primary composite outcome (all-cause death, myocardial infarction, stroke, and major bleeding) and a secondary ischemic composite outcome at 1-year follow-up.
The primary composite outcome did not differ significantly between the deferral and PCI groups across SYNTAX score categories at 1 year.
In patients with severe coronary disease (SYNTAX score >17), the ischemic composite outcome occurred more frequently in the deferral group compared with the PCI group (30.9% vs 14.8%; adjusted HR: 2.43; 95% CI: 1.04-5.64; P = 0.04), driven primarily by death and stroke.
Bleeding complications were consistently lower in the deferred PCI group across all SYNTAX score categories.

Study Design

Type

RCT (n=466)

Randomization

Randomized to deferral of PCI or PCI before TAVR

Structured PICO

Does deferral of percutaneous coronary intervention compared to PCI before TAVR impact outcomes in patients with significant coronary artery disease based on their SYNTAX score?

P

Population

466 patients with significant coronary artery disease undergoing TAVR, randomized to deferral of PCI or PCI before TAVR, followed for 1 year.

I

Intervention

Deferral of percutaneous coronary intervention (PCI) before TAVR

C

Comparator

Percutaneous coronary intervention (PCI) before TAVR

O

Outcome

Composite of all-cause mortality, myocardial infarction, stroke, and major bleeding at 1 yearcomposite

While deferring PCI prior to TAVR appears safe across overall coronary disease severity categories, patients with more complex disease (SYNTAX score >17) may face an increased risk of ischemic events if PCI is deferred.

Limitations

Post hoc findings require confirmation in randomized trials
Post hoc analysis requiring confirmation in randomized trials

Key expert perspectives

Captured external expert commentary on this paper, strongest first. Original sources are linked where available.

GM Gijs M. BroezeResearcher, Amsterdam University Medical Centers

“These findings suggest that the extent of CAD should be incorporated into decision-making for TAVR patients with concomitant coronary disease, but confirmation from randomized studies is needed”

News Coverage

Implication

Deferral of PCI before TAVR may be safe at 1 year in selected patients; leaves open SYNTAX-guided decisions and longer-term outcomes.

Abstract

BACKGROUND: Coronary artery disease is present in one-half of patients undergoing transcatheter aortic valve replacement (TAVR). The recent randomized controlled PRO-TAVI (Percutaneous Coronary Intervention Before Transcatheter Aortic Valve Implantation) trial indicated that deferral of percutaneous coronary intervention (PCI) is safe in patients with concomitant coronary artery disease at 1-year follow-up. The SYNTAX (Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery) score quantifies the extent of coronary artery disease, which may guide individualized revascularization strategies. OBJECTIVES: The aim of this study was to evaluate the association between SYNTAX score (SS) and clinical outcomes in patients undergoing TAVR. METHODS: This study was a substudy of the PRO-TAVI trial, including 466 patients with significant coronary artery disease undergoing TAVR randomized to deferral of PCI or PCI before TAVR. SS was calculated from preprocedural coronary angiograms, and patients were stratified by SS quartiles. The primary outcome was a composite of all-cause mortality, myocardial infarction, stroke, and major bleeding at 1 year. An ischemic composite outcome of all-cause mortality, myocardial infarction, and stroke was also assessed. RESULTS: The primary composite outcome did not differ across SS categories between the deferral and PCI groups at 1-year follow-up, which was completed by all but 1 patient. In patients with SS >17, the ischemic composite outcome occurred more often in the deferral group (30.9% vs 14.8%; adjusted HR: 2.43; 95% CI: 1.04-5.64; P = 0.04), driven primarily by all-cause mortality and stroke. Bleeding events were less frequent in the deferral group across all SS subgroups. CONCLUSIONS: In patients with concomitant coronary artery disease undergoing TAVR, deferral of PCI reduced bleeding risk and appeared safe across all SS categories. Deferral of PCI in patients with more complex coronary artery disease (SS >17) was associated with higher risk for the ischemic composite outcome. These post hoc findings require confirmation in randomized trials. (Percutaneous Coronary Intervention Before Transcatheter Aortic Valve Implantation [PRO-TAVI]; NCT05078619).

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Cite This Study

Broeze et al. (2026) conducted an RCT in Concomitant coronary artery disease in patients undergoing TAVR (n=466). Deferral of percutaneous coronary intervention (PCI) vs. PCI before TAVR was evaluated on Composite of all-cause mortality, myocardial infarction, stroke, and major bleeding at 1 year. Deferral of PCI before TAVR in patients with SYNTAX score >17 was associated with higher risk for the ischemic composite outcome compared to PCI (30.9% vs 14.8%; HR 2.43; 95% CI 1.04-5.64; P=0.04).

synapsesocial.com/papers/6acfd7eacc9784cabb8f8d97 https://doi.org/10.1016/j.jcin.2026.07.034