PCI Prior to TAVI of Only Modest Benefit in Patients With CAD and Aortic Stenosis

PARIS, France—For patients who have coronary artery disease and aortic stenosis, there is only a small reduction in the risk of major adverse cardiovascular events if they are treated with PCI ahead of TAVI, according to a patient-level meta-analysis presented this week at EuroPCR 2026.

The analysis included four randomized trials—ACTIVATION, FAITAVI, NOTION-3, and the Transcatheter Valves and Vessels (TCW) study—and showed there was a 30% lower relative risk of MACE with PCI compared with optimal medical therapy, a benefit driven by a lower risk of unplanned revascularizations.

Given the modest benefit, as well the results of the recent PRO-TAVI trial that found no advantage to revascularization ahead of TAVI, lead researcher Roberto Scarsini, MD, PhD (University of Verona, Italy), said the data suggest “routine PCI may provide only a limited advantage compared with conservative management” using optimal medical therapy in patients with coronary artery disease undergoing TAVI.

Presentation EuroPCR 2026

Coronary revascularisation in patients undergoing TAVI: an IPD meta-analysis of four randomised trials

“There’s no difference in mortality or other outcomes,” said Scarsini. The likelihood of less need for unplanned revascularization down the road can be used to inform patients prior to TAVI, but other variables, including age and frailty, should also be taken into consideration, he said.  

At the American College of Cardiology 2026 Scientific Session, the PRO-TAVI investigators showed that deferring revascularization is a safe strategy in patients with both coronary artery disease and aortic stenosis who are scheduled for TAVI. At 1 year, the risk of all-cause mortality, MI, stroke, or major bleeding was no different in those randomized to PCI before TAVI and those assigned to the deferred strategy. Rates of major bleeding were significantly lower in the deferral group than in those who had PCI ahead of TAVI.

EuroPCR Course Director Thomas Cuisset, MD, PhD (CHU La Timone, Marseille, France), said that angiography-guided PCI has been performed in TAVI candidates for years, mostly because of the surgical concept of bypassing lesions when replacing the aortic valve. However, TAVI patients with coronary artery disease are often stable, without angina, but at high risk of bleeding, he said. Cuisset pointed out that just 11% of patients in PRO-TAVI required PCI because of continuing or worsening symptoms after TAVI.

“We can probably move away from routine to very selective PCI, not before, but after TAVI, if needed,” said Cuisset. “There is no benefit of routine PCI before TAVI.”

Driven by Fewer Revascularizations

Prior to PRO-TAVI, several other studies also attempted to understand how best to proceed in patients with concomitant coronary artery disease and aortic stenosis.

The ACTIVATION trial showed no advantage to performing PCI before TAVI, but the NOTION-3 trial suggested there was a reduction in MACE if patients were treated with PCI first. In FAITAVI, clinical events were reduced with FFR-guided PCI compared with angiography-guided PCI in patients with coronary disease and aortic stenosis. The TCW trial compared PCI and TAVI to combined SAVR and CABG surgery in patients with concomitant disease.  

The meta-analysis included those four randomized trials, but not PRO-TAVI since it was published in late March. In all, 694 patients (mean age 83.1 years; 37% female) were treated with PCI ahead of TAVI, including 439 who underwent FFR-guided PCI and 255 who underwent angiography-guided PCI, while 356 patients (82.1 years; 34% female) were treated with optimal medical therapy. Nearly 54% of patients were revascularized before TAVI and 36% had a concomitant procedure.

“The baseline clinical characteristics of the cohort [reflect] a typical TAVI cohort, very elderly,” Scarsini told TCTMD. “About 20% to 30% of patients were symptomatic for angina at baseline.”

At 1 year, the rate of MACE was 8.4% in the PCI-treated patients versus 14.3% in the medical therapy arm (HR 0.70; 95% CI 0.49-0.99). There was no difference in the risk of all-cause mortality, cardiovascular mortality, MI, or stroke, but unplanned revascularizations were less common in the PCI-treated patients (HR 0.34; 95% CI 0.14-0.80). There was no difference in the rate of net adverse clinical events (NACE), an endpoint that factors in bleeding risks.

Stratified by revascularization strategy, there was an observed reduction in MACE and NACE with FFR-guided PCI over medical therapy. That reduction was not seen in patients who underwent angiography-guided PCI.

“There is a strong signal for significant benefit in patients who underwent FFR-guided PCI,” said Scarsini. “This is something that was similar to what was observed in the FAITAVI trial as well.” He also noted that FAITAVI showed physiology with FFR can be reliably assessed in the vast majority of patients.

During the discussion, Cuisset questioned whether there’s any need for invasive coronary angiography. In his practice, the pre-TAVI CT assessment is sufficient, and if there is no significant coronary artery disease, they’ll proceed with TAVI alone. If there is significant disease, or if the CT is inconclusive, “we will just check the coronary artery during the TAVI procedure because we have a 14-Fr sheath in the femoral artery,” he said. “It’s very convenient to check the coronaries.”

To TCTMD, Scarsini said a coronary angiogram is still standard at his center, either before TAVI or during the procedure. He added that they are also quite comfortable assessing coronary physiology in the setting of aortic stenosis, which they do in intermediate lesions.

“In clinical practice, in terms of whether to revascularize or not, it’s a very tailored decision,” he said. “In Europe, probably less so in the US, we treat very elderly patients who may be frail or have many comorbidities. It’s not unreasonable to leave a coronary lesion untreated [and to treat with] medical therapy in a very frail patient and to reassess after TAVI. That’s something I would say is quite common in clinical practice.”

Although there was only a small benefit of PCI in their meta-analysis, Scarsini said further follow-up is warranted, noting that there was a signal toward a reduction in other endpoints, such as cardiovascular mortality, MI, and stroke. “I think we need more data,” he said. The strongest signal of benefit with revascularization comes from NOTION-3, a study that included patients with FFR-positive lesions or those with at least 90% stenosis, he noted.

Others on the panel highlighted some limitations of the meta-analysis, noting there is heterogeneity across the trials, including differences in the primary endpoints. Davide Capodanno, MD, PhD (University of Catania, Italy), one of the panelists, said the obvious next step is to contact the PRO-TAVI investigators to include that trial in an updated meta-analysis.