Association Between Revascularization Timing and Outcomes for Coronary Artery Disease in Patients Undergoing Transcatheter Aortic Valve Implantation

Coronary artery disease (CAD) is common in patients with severe aortic stenosis (AS), yet the optimal timing of coronary revascularization in patients undergoing transcatheter aortic valve implantation (TAVI) remains uncertain. We retrospectively analyzed consecutive patients with severe AS and stable CAD, defined as fractional flow reserve ≤0.80, instantaneous wave-free ratio ≤ 0.89, or visual stenosis ≥90%, who underwent TAVI between October 2013 and July 2023. Patients were categorized into two groups: PCI-first and TAVI-first. The primary endpoint was 1-year incidence of major adverse cardiac events (MACE: all-cause mortality, myocardial infarction, and unplanned revascularization). The secondary endpoint was 3-year MACE stratified by PCI after TAVI among the TAVI-first group. Of 1126 TAVI patients, 209 met criteria for concomitant CAD (PCI-first, n = 112; TAVI-first, n = 97). The TAVI-first group had lower frailty and fewer New York Heart Association functional class III/IV symptoms, whereas the PCI-first group had more blood transfusions. At 1 year, the crude incidence of MACE was higher in the PCI-first group, although this difference was not significant after propensity score adjustment (HR 1.62; 95% CI 0.60-5.2; p = 0.36). Among TAVI-first group, patients who underwent PCI after TAVI had a lower incidence of MACE (log-rank p = 0.007), but the 90-day landmark analysis showed no significant difference (0/24 vs. 5/62 events; log-rank p = 0.23). In patients with severe AS and CAD, a PCI-first strategy was associated with a higher incidence of bleeding and transfusion without improvement in short-term outcomes. A TAVI-first strategy with selective PCI during follow-up may be a reasonable alternative, although the long-term benefit of post-TAVI PCI awaits confirmation in randomized trials.