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TAVI PCIStructural HeartNew England Journal of Medicine
Timing of Percutaneous Coronary Intervention Relative to Transcatheter Aortic-Valve Implantation
Timing of PCI in Patients Undergoing Transcatheter Aortic-Valve Implantation
View Full PaperWhy the trial?
Many patients undergoing TAVI have concomitant coronary artery disease, yet whether PCI should be performed before or after the valve procedure had never been randomised, leaving the sequencing decision to local practice.
Does a strategy of TAVI before PCI reduce adverse clinical events in patients with severe aortic stenosis and coronary artery disease compared to PCI before TAVI?
Population
986 patients with severe aortic stenosis and coronary artery disease
Comparison
TAVI-first vs PCI-first treatment sequence
Design
International, open-label, randomized noninferiority trial (48 European centres)
Follow-up
1 year
Key result
TAVI before PCI was noninferior to PCI before TAVI for the primary composite endpoint at 1 year (22.2% vs 24.2%; risk difference -2.0 percentage points; P<0.001 for noninferiority).
Authors
Discussion
Key questions
Member takes
Where experts stand
Experts broadly accept that TAVI PCI confirms a TAVI-first strategy is a noninferior option, though several note the trial's low-complexity coronary disease limits its applicability to harder cases.
Most commentators read this as a clean noninferiority result that supports doing the valve first when both TAVI and PCI are planned, simplifying procedural sequencing in practice. Some voices flag that the study population had low-complexity coronary disease and nearly all balloon-expandable valves, raising questions about generalizability. The live question is whether these findings hold in patients with more advanced coronary anatomy or self-expanding valves.
Agreement
Multiple clinicians agree the trial establishes TAVI-first as a viable sequencing option that matches PCI-first on the primary composite endpoint at one year.
4 clinicians say this directly
2 takes classified by contention axis so far — the map appears as more land.
Still unclear
Whether the results apply to patients with higher-complexity coronary disease (median SYNTAX score was only 10) or with self-expanding valves remains untested. It is also unclear whether the higher rate of PCI omission after TAVI-first (12.7% vs 3.5%) reflects appropriate deferral or could become a concern over longer follow-up. Guideline committees have yet to signal whether this trial will change formal recommendations on procedural sequencing.
Key expert perspectives
No need for upfront PCI in TAVI patients unless clinically indicated
Garzon interprets the result as supporting a TAVI-first approach and argues PCI should follow only when clinically indicated after the valve is in. He also noted more bleeding in the PCI-first group, though the difference was not significant.
Distilled from their postX post
Similar outcomes but only 25% multivessel disease in the study population
Biondi-Zoccai highlights that TAVI before PCI yielded similar outcomes to PCI before TAVI at one year but flags that only about 25% of patients had multivessel disease, suggesting a relatively low-risk coronary cohort.
Distilled from their postX post
MGMartha GulatiCardiologistPractice takeBefore results
Evidence catching up to what clinicians already do in practice
In a pre-result post previewing the Hot Line session, Gulati characterized the PCI-timing question around TAVI as evidence catching up to clinical practice.
Distilled from their postX post
Overview
PCI timing in TAVR patients with CAD remains unresolved; leaves open whether omitting routine pre-TAVR PCI is safe.
Key Points
- To evaluate whether performing transcatheter aortic-valve implantation (TAVI) before percutaneous coronary intervention (PCI) is noninferior to performing PCI before TAVI in patients with severe aortic stenosis and coronary artery disease.
- International, open-label, randomized noninferiority trial conducted across 48 centers in Europe (N=986; NCT04310046).
- Participants were randomly assigned in a 1:1 ratio to receive either TAVI before PCI (TAVI-first group, n=498) or PCI before TAVI (PCI-first group, n=488).
- The primary end point was a 1-year composite of all-cause mortality, nonfatal myocardial infarction, ischemia-driven revascularization, rehospitalization related to the valve, procedure, or heart failure, or major/disabling/life-threatening bleeding (noninferiority margin: 6.6 percentage points).
- A primary end-point event occurred in 105 patients (22.2%) in the TAVI-first group and 112 patients (24.2%) in the PCI-first group (risk difference, −2.0 percentage points; 95% CI, −7.4 to 3.4; P<0.001 for noninferiority).
- Serious adverse events were reported in 264 patients in the TAVI-first group and in 273 patients in the PCI-first group.
Evidence details
What drove the result?
| Outcome | TAVI first | PCI first |
|---|---|---|
| Death, MI, revascularization, rehospitalization, or major bleeding | 105 (22.2%) | 112 (24.2%) |
| Primary composite · RD −2.0 pp (95% CI −7.4 to 3.4); noninferior (margin 6.6 pp; p<0.001) | ||
Limitations & tradeoffs
Safety
Serious adverse events occurred in 264 vs 273 patients (of 498 vs 488 randomized).
Design limitations
The trial was open-label, and individual components of the composite are not reported in the abstract.
Statistical certainty
Noninferiority was defined against a wide 6.6-percentage-point margin, and reported percentages do not match crude counts over the randomized Ns, implying an analysis population not detailed in the abstract.
Structured PICO
Does a strategy of TAVI before PCI reduce adverse clinical events in patients with severe aortic stenosis and coronary artery disease compared to PCI before TAVI?
P
Population
986 patients with severe aortic stenosis and coronary artery disease followed for 1 year.
I
Intervention
Transcatheter aortic-valve implantation (TAVI) performed before percutaneous coronary intervention (PCI) (TAVI-first strategy)
C
Comparator
Percutaneous coronary intervention (PCI) performed before TAVI (PCI-first strategy)
O
Outcome
Composite of death from any cause; nonfatal myocardial infarction; ischemia-driven revascularization; rehospitalization related to the valve, procedure, or heart failure; or life-threatening, disabling, or major bleeding at 1 year after randomizationcomposite
In patients with severe aortic stenosis and concomitant coronary artery disease, a strategy of performing TAVI before PCI is noninferior to PCI before TAVI regarding a 1-year composite clinical endpoint.
Main Result
Effect estimate: risk difference -2.0 percentage points (95% CI -7.4 to 3.4)
Absolute Event Rate: 22.2% vs 24.2%
Absolute Risk Reduction: 2%
p-value: p=<0.001 for noninferiority
Coverage & sources
Journal, society, and media accounts. Useful signal, not independent expert judgment.
Cite This Study
Stähli et al. (2026) conducted an RCT in Severe aortic stenosis and coronary artery disease (n=986). TAVI before PCI (TAVI-first) vs. PCI before TAVI (PCI-first) was evaluated on Composite of death from any cause; nonfatal myocardial infarction; ischemia-driven revascularization; rehospitalization related to the valve, procedure, or heart failure; or life-threatening, disabling, or major bleeding at 1 year (risk difference -2.0 percentage points, 95% CI -7.4 to 3.4, p=<0.001 for noninferiority). TAVI before PCI was noninferior to PCI before TAVI for the primary composite endpoint at 1 year (22.2% vs 24.2%; risk difference -2.0 percentage points; P<0.001 for noninferiority).