Coronary Revascularization in the Era of TAVR: Timing, Strategy, and Outcomes

Area of Science:

• Cardiology
• Interventional Cardiology
• Cardiac Surgery

Background:

• Coronary artery disease (CAD) frequently coexists with severe aortic stenosis requiring transcatheter aortic valve replacement (TAVR).
• The optimal timing for percutaneous coronary intervention (PCI) in TAVR patients is a complex clinical decision with no established consensus.
• Balancing the risks and benefits of PCI before, during, or after TAVR is challenging.

Purpose of the Study:

• To critically evaluate existing evidence on various PCI timing strategies in TAVR patients.
• To identify uncertainties and complexities in managing patients with both CAD and severe aortic stenosis.
• To synthesize findings from randomized trials and observational studies on PCI timing relative to TAVR.

Main Methods:

• Review of randomized controlled trials (e.g., ACTIVATION, NOTION-3).
• Analysis of observational registry data (e.g., REVASC-TAVI, National Readmissions Database).
• Synthesis of findings from recent meta-analyses on PCI timing and TAVR outcomes.

Main Results:

• Pre-TAVR PCI showed a modest reduction in ischemic events but increased bleeding risk.
• Pre- and peri-TAVR PCI strategies were associated with higher complication rates and no clear long-term mortality benefit.
• No specific PCI timing strategy demonstrated a definitive advantage in reducing long-term mortality.
• Individual patient factors like anatomy, frailty, bleeding risk, and valve type are crucial for decision-making.

Conclusions:

• A personalized, patient-centered approach is recommended for PCI timing in TAVR candidates.
• Standardized PCI timing protocols are not supported by current evidence.
• Further research is needed on risk stratification, imaging, and long-term outcomes to refine clinical guidelines.