Percutaneous Coronary Intervention for Coronary Artery Disease in Patients Undergoing Transcatheter Aortic Valve Replacement: Perspective on the PRO-TAVI Trial

Q: What is the clinical evidence from this study?

Study design: RCT. Population: Severe aortic stenosis and obstructive coronary artery disease (n=466). Intervention: Deferral of PCI vs. PCI before TAVR. Primary outcome: Composite outcome of all-cause mortality, MI, stroke, or major bleeding at 1-year follow-up (HR 0.89, 95% CI 0.62–1.28).

Keerthi T. Gondi; Gustavo Hernandez; Ki Park

doi:10.15420/usc.2026.24

September 10, 2026US Cardiology ReviewOpen Access

Percutaneous Coronary Intervention for Coronary Artery Disease in Patients Undergoing Transcatheter Aortic Valve Replacement: Perspective on the PRO-TAVI Trial

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Why the study?

Does percutaneous coronary intervention before TAVR improve ischemic and clinical outcomes compared to medical therapy alone or deferred PCI in patients with severe aortic stenosis and obstructive coronary artery disease?

Key Points

To evaluate the clinical outcomes, trade-offs, and optimal timing of percutaneous coronary intervention in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement.
Synthesis of evidence from randomized clinical trials evaluating percutaneous coronary intervention (PCI) timing and efficacy prior to transcatheter aortic valve implantation (TAVI).
Analysis includes the PRO-TAVI trial (N=466) testing noninferiority of PCI deferral versus pre-TAVI PCI, and the NOTION-3 trial (N=455) comparing pre-TAVI PCI to medical therapy.
In the PRO-TAVI trial, the 1-year composite of all-cause mortality, MI, stroke, or major bleeding occurred in 24% of the deferral group and 26% of the PCI group (HR 0.89; 95% CI [0.62–1.28]), meeting noninferiority driven by reduced bleeding despite higher secondary ischemic outcomes (21% versus 16%).
In the NOTION-3 trial, the composite outcome of all-cause mortality, MI, or urgent revascularization at median 2-year follow-up was significantly lower with PCI than medical therapy (26% versus 36%; p=0.04), driven by fewer MIs and urgent revascularizations.
Deferred arms in both trials demonstrated relatively low subsequent revascularization rates of 10% to 11%.

Study Design

Type

RCT (n=466)

Blinding

Open-label

Randomization

Randomized

Structured PICO

Does percutaneous coronary intervention before TAVR improve ischemic and clinical outcomes compared to medical therapy alone or deferred PCI in patients with severe aortic stenosis and obstructive coronary artery disease?

P

Population

466 patients with severe aortic stenosis and obstructive coronary artery disease of predominantly low anatomic complexity, followed for 1 year.

I

Intervention

Percutaneous coronary intervention (PCI) performed before transcatheter aortic valve replacement (TAVR).

C

Comparator

Medical therapy alone (NOTION-3) or deferral of PCI (PRO-TAVI).

O

Outcome

Composite of all-cause mortality, MI, or urgent revascularization at median 2-year follow-up (NOTION-3); Composite of all-cause mortality, MI, stroke, or major bleeding at 1-year follow-up (PRO-TAVI).composite

Main Result

Hazard Ratio: 0.89 (95% CI 0.62–1.28)

Absolute Event Rate: 24% vs 26%

Limitations

Open-label design may have influenced event rates.
Excluded patients with high-risk CAD, including left main (LM) disease, which may limit generalizability to clinical practice.
Both studies were open-label, which may have influenced event rates
The unblinded design of NOTION-3 may have contributed to the higher rates of urgent revascularization in the medical therapy arm
These trials excluded patients with high-risk CAD, including left main (LM) disease, which may limit generalizability to patients seen in clinical practice

Key expert perspectives

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

MV Michiel VoskuilInterventional cardiologist, University Medical Center Utrecht

“For elderly TAVR patients with concomitant coronary artery disease, I think it's safe to first do TAVR and see if patients will still have complaints about chest pain or tightness. We can wait and, if they still have complaints afterward, only then do PCI.”

University Medical Center UtrechtConference Coverage

RDRonak DelewiInterventional cardiologist, Amsterdam UMC

“By performing PCI, the blood vessel opens up again, but PCI in these patients is burdensome and not without risk. In the PRO-TAVI study, we wanted to know if it is safe to omit the standard PCI before the TAVI procedure. We now see that it is possible: it is less burdensome for the patient and reduces the risk of bleeding.”

Amsterdam University Medical CentersNews Coverage

GMGijs 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.”

Amsterdam University Medical CentersNews Coverage

Implication

Pre-TAVR PCI is superior to medical therapy alone and may improve ischemic outcomes compared to deferred PCI in select patients with severe aortic stenosis and obstructive CAD, though it increases the risk of bleeding.

Abstract

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Discussion

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Cite This Study

Gondi et al. (2026) conducted an RCT in Severe aortic stenosis and obstructive coronary artery disease (n=466). Deferral of PCI vs. PCI before TAVR was evaluated on Composite outcome of all-cause mortality, MI, stroke, or major bleeding at 1-year follow-up (HR 0.89, 95% CI 0.62–1.28).

synapsesocial.com/papers/6ad1157b00741cc3fba7d4a8 https://doi.org/10.15420/usc.2026.24

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Percutaneous Coronary Intervention for Coronary Artery Disease in Patients Undergoing Transcatheter Aortic Valve Replacement: Perspective on the PRO-TAVI Trial

Key Points

Study Design

Structured PICO

Main Result

Limitations

Key expert perspectives

Implication

Abstract

Discussion

Cite This Study

Percutaneous Coronary Intervention for Coronary Artery Disease in Patients Undergoing Transcatheter Aortic Valve Replacement: Perspective on the PRO-TAVI Trial

Key Points

Study Design

Structured PICO

Main Result

Limitations

Key expert perspectives

Implication

Abstract

Discussion

Cite This Study

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