On Tuesday, February 28, 2023, Dr. Michael Joner presented the late-breaking trial entitled “Comparison of Different Percutaneous Revascularization Timing Strategies in Patients Undergoing Transcatheter Aortic Valve Implantation (TAVI),” which is a sub analysis of the REVASC-TAVI registry. This study is a multicenter, international study that enrolled patients with symptomatic severe aortic stenosis and coronary artery disease who underwent staged or concomitant percutaneous coronary intervention (PCI) from January 2015 to September 2021. A total of 1617 patients were assigned to three different groups 1) PCI before TAVI (PCI planned and completed prior to TAVI n=1052) 2) Concomitant PCI and TAVI (planned PCI during the index TAVI either before or after valve deployment n=394) 3) PCI after TAVI (planned PCI after the TAVI in a different setting n=152). The primary outcome was 2-year all-cause death with a co-primary composite endpoint of all cause death, stroke, re-hospitalization for congestive heart failure (CHF), and myocardial infarction. At two years, PCI after TAVI had a lower all cause death rate (6.8%) compared to PCI before TAVI (20.6%) and concomitant PCI (20.1%). The composite endpoint of all cause death, stroke, re-hospitalization for CHF, and myocardial infarction was also lower in the PCI after TAVI group (17.4%) compared to PCI before TAVI (30.4%) and concomitant PCI (30%).

Why is this study important?

The prevalence of coronary artery disease (CAD) in patients with symptomatic severe aortic stenosis undergoing TAVI ranges from 15-85%. The early PARTNER trials required that patients with concomitant CAD undergo PCI prior to TAVI. Several studies have confirmed that PCI prior to TAVI is safe and feasible. The current guidelines give a Class IIa recommendation for PCI prior to TAVI in patients with left main or proximal CAD. However, the management of concomitant CAD in TAVI patients remains controversial regarding the clinical benefit of revascularization as well as optimal timing.

Should I change my practice because of these findings?

In general, this trial should not change your practice as there are still certain clinical situations in which PCI prior to TAVI may be beneficial which is still yet to be defined.  However, this trial does support the deferral of PCI in some TAVI patients and suggests that it may be associated with better outcomes. As with the trial investigators, clinical judgement by the heart team is still necessary in deciding when to PCI patients with CAD undergoing TAVI.

What question was this study supposed to answer?

This study aimed to evaluate the different timing of revascularization in patients undergoing TAVI.  They compared PCI before TAVI vs. concomitant PCI vs. PCI after TAVI.

What did the study show?

PCI performed after TAVI was associated with lower rates of all cause death at two years compared to PCI before TAVI or concomitant PCI and TAVI. PCI after TAVI was also associated with lower rates of the composite endpoint of death, myocardial infarction, stroke or rehospitalization from CHF.

How good was the approach/methodology?

This is a multi-center international, retrospective, non-randomized sub analysis of the REVASC-TAVI registry.  There are several limitations which include non-randomized data, sub analysis of a prior study, and treating physicians determined timing of PCI which introduces selection bias and doesn’t account for confounding factors.  While it does show patients may have better outcomes with PCI post-TAVI further investigation is still needed. 

All editors: Tamara Atkinson, MD, FSCAI