Here’s a bold statement: Patients with both severe aortic stenosis (AS) and obstructive coronary artery disease (CAD) who undergo Transcatheter Aortic Valve Implantation (TAVI) face no additional penalties in survival, quality of life, or clinical outcomes compared to those without CAD. But here's where it gets controversial—despite the conventional wisdom of 'fixing everything while you’re there,' performing Percutaneous Coronary Intervention (PCI) around the time of TAVI doesn’t seem to offer clear benefits and may even expose vulnerable patients to unnecessary risks. This finding challenges long-held surgical philosophies and invites a reevaluation of how we approach these complex cases.
A recent post hoc analysis of the SCOPE I trial, published in JAMA Network Open, sheds light on this issue. The study included 732 patients (average age 82, 56.8% female) with symptomatic severe AS who underwent TAVI. Among them, 51% had obstructive CAD, and 38.6% of these patients underwent elective PCI around the time of TAVI. Surprisingly, after three years, there were no statistically significant differences in survival, quality of life, or clinical efficacy between patients with and without CAD. Quality of life scores, measured by the Kansas City Cardiomyopathy Questionnaire (KCCQ), improved similarly in both groups, rising from baseline medians of 54.2 (CAD) and 55.2 (no CAD) to 79.7 and 82.3, respectively. Similarly, risks of all-cause mortality, cardiovascular mortality, and clinical efficacy (freedom from major adverse events) were comparable.
And this is the part most people miss—while there were trends toward higher risks of myocardial infarction (MI) and unplanned PCI in patients with CAD, these differences were not statistically significant. Even more intriguing, clinical outcomes did not differ between patients who received PCI and those who did not, except for a slightly higher risk of bleeding in the PCI group. This raises a thought-provoking question: Are we over-intervening in these patients, potentially causing more harm than good?
Giuseppe Tarantini, MD, PhD, who was not involved in the study, noted that the findings are ‘more reassuring than surprising.’ He highlighted the striking contrast between the ‘fix everything’ approach in surgical aortic valve replacement (SAVR) + coronary artery bypass grafting (CABG) and the emerging evidence in TAVI, where upfront revascularization may not be beneficial—and could even be harmful—for stable CAD patients. This shift in perspective underscores the need for a tailored, patient-centered approach in TAVI candidates.
The NOTION-3 trial previously suggested that PCI before TAVI could reduce major adverse cardiovascular events (MACE) in patients with stable CAD, but this benefit was driven primarily by the need for coronary revascularization. Another observational study supported the idea that obstructive CAD might be better left untreated before TAVI. These conflicting findings highlight the complexity of managing patients with both AS and CAD, leaving clinicians with more questions than answers.
In an accompanying editorial, Eric Warner, MD, and Rishi Puri, MD, PhD, emphasized that the optimal management of CAD in TAVI candidates remains an evolving field. They suggested that stable patients with CAD can safely defer PCI, with TAVI performed under single antiplatelet therapy. They proposed a ‘most balanced overall strategy’ that includes close clinical surveillance post-TAVI and a low threshold for PCI in significant lesions within the first six months. However, they also acknowledged the need for further research to identify which patients truly benefit from PCI and when it should be performed.
Tarantini pointed out several unresolved challenges, including the need to better integrate anatomy with functional significance in patients with severe AS, the timing of PCI relative to TAVI, and the delicate balance between ischemia and bleeding risks. He also stressed the importance of valve choice in influencing revascularization strategies and called for a more consistent, heart team-friendly approach that considers clinical presentation, lesion severity, physiology, bleeding risk, frailty, and valve selection.
Here’s a question to ponder: Should guidelines more clearly distinguish between surgical and transcatheter philosophies, especially when it comes to PCI in TAVI patients? And how can we better align interventions with what patients truly need, rather than defaulting to a ‘fix everything’ mindset?
Both Tarantini and investigator Daijiro Tomii, MD, underscored the importance of including quality-of-life endpoints in future studies. As Tarantini concluded, ‘The next step isn’t more revascularization—it’s better selection, better timing, and better alignment with what patients actually need.’ This shift in focus could redefine how we approach these complex cases, prioritizing patient outcomes over procedural dogma. What’s your take? Do you agree that a more tailored, less interventionist approach is the way forward? Share your thoughts in the comments below!
