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Page 6 of 11 Raval et al. Vessel Plus 2024;8:5 https://dx.doi.org/10.20517/2574-1209.2023.99

The ACTIVATION trial is the only randomized controlled trial that compared elective, pre-TAVI PCI vs.
no PCI in patients with TAVI with significant CAD. Significant CAD was defined as ≥ 1 lesion of ≥ 70%
[36]
severity in a major epicardial vessel or 50% in a vein graft or protected left main lesion . Two hundred and
thirty-five patients were randomized to PCI vs. no PCI arms. No difference was noted in mortality or major
adverse cardiovascular and cerebrovascular events between the two groups. However, the PCI group was
[37]
noted to have a higher incidence of bleeding .
In AS patients with complex CAD and high-risk anatomy, when PCI is deemed necessary, residual
SYNTAX SCORE (rSS) has been a marker for effective revascularization, and various meta-analyses have
demonstrated a low rSS to be associated with better outcomes. In a prospective study by Stefanini et al. in
445 patients with AS and CAD with an intermediate risk SYNTAX score of > 22, less complete
[14]
revascularization was associated with worse clinical outcomes at 1 year . In another study by Witberg et al.
in 1,270 consecutive patients, it was noted that severe CAD with a SYNTAX score of > 22, and ICR as
defined by rSS of > 8, were both associated with increased mortality after a median follow-up of 1.9 years,
with hazard ratios of 2.09 and 1.72 respectively .
[38]
A meta-analysis of 13 studies comprising 8,334 patients showed that patients with CAD and SYNTAX score
of > 22 had higher 1-year mortality, and a low rSS of < 8 post-revascularization was associated with
decreased mortality . In another study, 287 consecutive patients by Witberg et al. showed that patients
[12]
with rSS of < 8 post-revascularization had similar outcomes compared to patients who did not have
CAD [12,39] .

Thus, in AS patients who are treated with PCI, more complete revascularization appears to have better
outcomes. This mirrors results from the recent randomized FIRE trial showing that physiology-guided
complete revascularization in patients aged above 75 years with MI with CAD was associated with a lower
risk of death, stroke, myocardial infarction, or ischemia-driven revascularization at 1 year .
[40]
Given these results, there remains a need for a stratified approach to managing stable CAD in TAVI
patients based on symptoms, physiologic severity and extent of the disease, and coronary artery anatomy.
The current guidelines stating PCI should be considered in patients undergoing TAVI with a coronary
artery diameter stenosis of > 70% need revision. These guidelines were framed when TAVI was mainly
performed in patients > 75 years of age. With an increase in TAVI in the < 75-year-old population,
extrapolation of these guidelines may not be appropriate. Patients who are asymptomatic and have single
vessel CAD may not need to be revascularized pre-TAVI, even if they have > 70% proximal stenosis.
Revascularization would commit the patient to dual antiplatelet therapy (DAPT) pre-TAVI, increasing
bleeding risks in addition to possible higher vascular complications during TAVI. On the other hand, if
involvement includes left main (LM) with ≥ 50% stenosis or left anterior descending (LAD) with > 70%
proximal stenosis, it may be reasonable to pursue PCI with TAVI.

Revascularization with CABG needs to be considered along with SAVR in younger lower-risk patients
despite the extension of TAVI in this population. The prognostic value of PCI (especially with multivessel
disease) in stable CAD is less clear, whereas CABG has shown consistent benefit [35,41] . Thus, despite TAVI
being extended to younger patients, in patients with comorbid stable CAD, the option of SAVR with CABG
should be considered. The ongoing TransCatheter Valve and Vessels Trial (NCT 03424941) - randomized
FFR-guided PCI and TAVI vs. CABG and SAVR - will answer the question of whether PCI and TAVR are
noninferior to CABG and SAVR.