When to perform percutaneous coronary interventions in TAVI patients? Recent advances

Coronary artery disease (CAD) is prevalent in c. 50% of patients with severe aortic valve stenosis undergoing transcatheter aortic valve implantation (TAVI). The impact of CAD on TAVI outcomes and optimal management strategies remains unclear. This article considers the latest evidence on assessing CAD in TAVI patients and determining the timing for treating it to optimize clinical outcomes and resource utilization. We discuss the current methods for CAD diagnosis, including invasive coronary angiography (ICA), coronary computed tomography angiography, and the role of functional assessment indices such as fractional flow reserve and instantaneous wave-free ratio in guiding revascularization decisions. While ICA remains the standard for determining CAD severity in TAVI candidates, coronary computed tomography angiography has shown the potential to reduce unnecessary ICA procedures. When indicated, fractional flow reserve seems more reliable than the instantaneous wave-free ratio in aortic valve stenosis patients, particularly when evaluated post-TAVI. Recent data suggests that percutaneous coronary intervention post-TAVI may be associated with improved outcomes compared to pre-TAVI interventions. In summary, the optimal management of CAD in TAVI patients is still under investigation. The current evidence supports a tailored approach, considering pre- and post-TAVI percutaneous coronary intervention strategies based on individual patient characteristics and procedural complexities. Further randomized trials are needed to establish definitive guidelines.