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Raval et al. Vessel Plus 2024;8:5 https://dx.doi.org/10.20517/2574-1209.2023.99 Page 7 of 11

Optimal timing of revascularization: before, during, or after TAVI?
The optimal timing of PCI in patients who undergo TAVI remains uncertain. When the decision is made to
[32]
pursue PCI, it is usually performed prior to TAVI . This offers the advantages of improving coronary flow
prior to TAVI and thus preventing ischemia during rapid pacing and times of hypoperfusion during the
[42]
TAVI procedure . PCI potentially reduces the risk of periprocedural myocardial infarction or ischemic
arrhythmias. However, there is concern about the risk of hemodynamic instability during complex PCI
before the treatment of severe AS , and dual antiplatelet therapy required post-PCI increases the bleeding
[43]
risk during TAVI.

Van Rosendael et al. assessed the impact of the timing of planned PCI on TAVI outcomes . Patients either
[44]
received PCI within 30 days pre-TAVI or greater than 30 days pre-TAVI. Results showed an increased
incidence of bleeding and vascular complications in the group that received PCI < 30 days prior to TAVI.
No other major differences were reported.

Concomitant PCI and TAVI offers the benefit of avoiding multiple vascular punctures, avoiding pre-
[45]
procedure DAPT, and lowering the cost of the procedures . However, this approach is associated with the
use of more contrast, risking acute kidney injury (AKI) . In a retrospective study of 22,344 patients from
[1]
the Nationwide Inpatient Sample database of the United States by Singh et al., 21,736 (97.3%) patients
underwent isolated TAVI and 608 (2.7%) patients underwent simultaneous TAVI and PCI. There were
significantly higher rates of mortality, vascular injury requiring surgery, and respiratory and infectious
[46]
complications in patients who received simultaneous TAVI and PCI compared to isolated TAVI .
However, a prospective study of 604 patients by Barbanti et al. reported that patients undergoing TAVI and
PCI simultaneously had similar mortality and morbidities of stroke, transient ischemic attack, life-
threatening bleeding, major bleeding, need for permanent pacemaker, and AKI in comparison to patients
who had TAVI without CAD or TAVI with CAD left untreated . A meta-analysis by Bao et al. showed
[47]
similar findings of non-significant differences in 30-day all-cause mortality, 30-day cardiovascular mortality,
1-year mortality, stroke, bleeding, and vascular complications in patients treated with isolated TAVI vs.
concomitant TAVI and PCI . A prospective study by Ochiai et al. also showed no difference in 2-year
[48]
major cardiovascular and cerebrovascular events irrespective of whether PCI was performed before,
[49]
concomitantly, or after TAVI .
Thus, most data show simultaneous PCI with TAVI is safe, but it is still not recommended, given the
potential increased procedure risk and risk for contrast AKI.

PCI after TAVI may be safer and more beneficial. Persistent symptoms of angina or dyspnea post-TAVI
would be clear indications for revascularization of obstructive CAD. Functional assessment of CAD with
invasive FFR appears more accurate post-TAVI, allowing more appropriate decision-making regarding
revascularization. High-risk PCI would be better tolerated in patients post-TAVI, and DAPT is avoided pre-
TAVI, helping reduce bleeding complications with TAVI . Recent data from a retrospective study by
[16]
Rheude et al. of 1,603 patients from the REVASC-TAVI registry noted significantly decreased 2-year
mortality in patients who received PCI post-TAVI (6.7%) compared to patients who received PCI pre-TAVI
(20.1%) and PCI concomitantly with TAVI (20.6%) . However, coronary access post TAVI through valve
[50]
struts, especially for the self-expanding CorValve with its taller frame, may be difficult. Dislodgement of the
[51]
transcatheter heart valve (THV) is also a concern . Despite these concerns, deferring PCI for stable
ischemia with the benefit of avoiding DAPT has become more accepted, since the most recent data support
stable CAD need not be revascularized pre-TAVI. 3D models can also be used for planning future coronary