[Comment] Coronary Revascularisation Before TAVI

Why It Matters

Deferring PCI simplifies the TAVI pathway, reduces bleeding risk and procedural costs, and supports a more selective, patient‑centred revascularisation strategy.

Key Takeaways

• Up to 50% TAVI patients have coronary artery disease
• PRO‑TAVI showed deferred PCI non‑inferior to routine PCI
• No increase in mortality or major adverse cardiac events
• Deferring PCI reduces bleeding risk and procedural time
• Guidelines may shift toward selective, not routine, revascularisation

Pulse Analysis

The coexistence of coronary artery disease (CAD) and severe aortic stenosis creates a therapeutic crossroads for the growing TAVI population. Approximately half of patients referred for transcatheter aortic valve implantation harbor obstructive lesions, yet the decision to intervene on the coronaries before valve deployment has been guided more by surgical precedent than robust evidence. Percutaneous coronary intervention adds catheter time, contrast load, and mandates dual antiplatelet or anticoagulant regimens, which can amplify bleeding in the elderly, frail cohort that typically undergoes TAVI. Consequently, clinicians have debated whether routine revascularisation truly improves outcomes or merely adds risk.

The PRO‑TAVI trial, published in The Lancet, provides the first adequately powered randomized comparison of routine PCI versus a strategy of deferral in TAVI candidates with significant CAD. In this multicenter, open‑label, non‑inferiority study, 1,200 patients were assigned to PCI before valve implantation or to proceed directly to TAVI, with coronary treatment reserved for ischemic symptoms or acute events. At 12‑month follow‑up, the composite of all‑cause mortality, myocardial infarction, stroke, and major bleeding was statistically equivalent between groups, and there was no signal of increased cardiovascular events in the deferred arm. These findings echo the earlier ACTIVATION trial, but PRO‑TAVI extends the evidence base with a larger sample and longer follow‑up.

The implications are immediate for heart teams managing TAVI patients. Deferring PCI can shorten procedural duration, lower contrast exposure, and diminish the need for intensified antithrombotic therapy, thereby reducing bleeding complications and health‑care costs. Moreover, the data support a more selective, physiology‑guided approach to coronary revascularisation, reserving intervention for lesions that are hemodynamically significant or symptomatic. As guideline committees incorporate these results, we can expect a shift away from blanket pre‑TAVI PCI toward individualized decision‑making, fostering safer pathways for an increasingly elderly and comorbid population.