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Raval et al. Vessel Plus 2024;8:5 https://dx.doi.org/10.20517/2574-1209.2023.99 Page 3 of 11

[12]
In another meta-analysis performed in 2018, comprising 13 studies and 8,334 patients treated with TAVI ,
there was no difference in 30-day or 1-year mortality comparing the presence or absence of CAD. Subgroup
analysis based on low (< 16), intermediate (16-22), and high (> 22) SYNTAX scores was also performed. In
the specific subgroup of patients with CAD and an intermediate or high SYNTAX score, there was an
increased 1-year mortality with an odds ratio of 1.71. The impact of percutaneous coronary intervention
(PCI) and residual SYNTAX score (rSS, the remaining SYNTAX score post-revascularization) on outcomes
was also studied, and an rSS of < 8 was associated with lower 1-year mortality with an odds ratio of 0.34.

Regarding the role of revascularization with PCI and TAVI, another systematic review and meta-analysis of
6 studies with 3,107 patients looked at the prognostic role of incomplete revascularization (ICR) and
[13]
reasonable ICR . ICR was defined as an rSS of > 8 in a majority of the studies, and reasonable ICR was
defined as an rSS of ≤ 8. There was significantly increased mortality in patients with ICR, with an odds ratio
of 1.69 compared to patients with reasonable ICR. Significant limitations of this study were that it included
observational studies prone to reporting the results without adjustment. This could result in confounding by
major comorbidities and, thus, could account for the increased mortality in the incomplete
revascularization group. In addition, incomplete revascularization was defined differently in different
studies.

Given these studies and other observational and retrospective studies, it does appear that the presence of
CAD is associated with worse outcomes in some subgroups of TAVI patients with complex CAD and high
SYNTAX scores [14,15] , and revascularization with PCI does improve intermediate and long-term mortality.
However, the benefit of PCI needs to be individualized. CAD is a highly diversified disease, and a more
stratified approach with guidelines on evaluation and management is currently not available.

Diagnostic evaluation of CAD prior to TAVI
Anginal chest pain and dyspnea on exertion are symptoms of both obstructive CAD and severe AS.
[1]
Distinguishing which symptom is related to either or both diseases can be difficult . Symptomatic patients
with severe AS are referred for TAVI, and an assessment of CAD is recommended prior to performing the
[5]
procedure .

Historically, invasive coronary angiography (ICA) has been performed in almost all patients undergoing
[1]
TAVI prior to performing the procedure or at the time of the procedure . Patients also receive a gated
cardiac computed tomography angiography (CTA) of the chest, abdomen, and pelvis as a part of a pre-
TAVI work-up for preprocedural planning including valve sizing and access approach, which usually does
not include imaging of the coronary arteries. With the increasing popularity of coronary CTA, simultaneous
cardiac and coronary CTA offers an alternative to traditional CTA. One of the major limitations of this is
that coronary CTA protocols often require the use of IV nitroglycerin or IV beta-blockers, which may not
be safe for patients with severe AS . In spite of this, as TAVI is being offered and even preferred in lower-
[1]
risk, relatively young patients who are less likely to have significant obstructive CAD, coronary CTA has
reasonable negative predictive value to exclude CAD, and decreases the chance of needing ICA . The
[16]
extent of coronary calcification on CT scan also provides further information.

A single-center, retrospective study in the United Kingdom of 491 patients assessed the utility and outcomes
of coronary CTA in patients undergoing TAVI. 76.3% of patients only received coronary CTA, and 21.7%
who had either a suspicious lesion on coronary CTA or an inability to assess coronary anatomy due to
severe coronary calcifications or motion artifacts also underwent ICA . Thus, coronary CTA was able to
[17]
avoid ICA in more than two-thirds of patients. Of the patients who received both coronary CTA and ICA,