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Page 2 of 12 Tagliari et al. Vessel Plus 2020;4:16 I http://dx.doi.org/10.20517/2574-1209.2020.05

patients with AS have other concomitant cardiovascular conditions demanding a combined approach. In
this scenario, the ability to perform TAVI combined with other transcatheter heart interventions becomes
crucial.

Here, we discuss some of the most frequent settings that have been considered for combined intervention
with TAVI, either concomitantly or staged.

PERCUTANEOUS CORONARY INTERVENTION
[1-3]
As the majority of patients with AS scheduled for TAVI are older than 75 years , it is not a surprise that
[4]
up to 50% of preoperative cardiac catheterizations reveal coexisting coronary artery disease (CAD) . In
high- and intermediate-risk TAVI trials, for instance, concomitant CAD was present in about two-thirds
of patients [2,5-7] , and even in the low-risk cohorts, concomitant coronary revascularization was indicated in
[8,9]
about 7% .
According to current European guidelines, percutaneous coronary intervention (PCI) should be considered
in patients with primary indication to undergo TAVI presenting with coronary artery diameter stenosis
[10]
> 70% in proximal segments (Class IIa, Level C) . It has not been addressed, however, as to when PCI
should be performed.

Simultaneous procedures have the advantage of decreasing repeated puncture or incision of vessels,
[11]
reducing patients’ suffering and length of hospital stay, and saving medical resources . However, radiation
[12]
exposure and the amount of contrast used are usually higher .
PCI before TAVI, on the other hand, has the potential to minimize ischemic risk during TAVI, particularly
during rapid ventricular pacing, and to overcome difficulties associated with coronary access post-TAVI.
Conversely, the patient remains at risk for valvular decompensation and needs to be put on dual antiplatelet
therapy, which may increase the risk of bleeding during TAVI [11-13] .

PCI after TAVI is relatively rare because prosthetic valve commissures, or stent frame, may be positioned
[14]
close to coronary ostia, interfering with coronary diagnostic or guiding catheters . Trying to facilitate
[15]
future coronary reaccess, Tang et al. have suggested some landmarks to predict coronary overlap severity
based on initial TAVI deployment orientation. These findings have significant implications as TAVI moves
to younger and low-risk patients, where valve durability and CAD progression are notable concerns. Neo-
commissure alignment thus becomes a new trend to be pursued during TAVI intervention.

Regarding scientific evidence supporting simultaneous or staged procedures, a systematic review of 4
studies, comprising 209 patients, showed no difference in 30-day mortality (OR = 1.47, 95%CI: 0.47-4.62),
renal failure (OR = 3.22, 95%CI: 0.61-17.12), periprocedural myocardial infarction (OR = 1.44, 95%CI: 0.12-
16.94), life-threatening bleeding (OR = 0.45, 95%CI: 0.11-1.87), and major stroke (OR = 3.41; 95%CI: 0.16-
[11]
74.2) when PCI was performed concomitant or staged with TAVI .
Similarly, a recent paper demonstrated no significant difference in life-threatening or major bleeding, and
acute kidney injury among patients who underwent planned pre-TAVI (n = 156), post-TAVI (n = 40), or
concomitant (n = 77) PCI. Cumulative 2-year mortality was also similar across the groups (29.7% vs. 14.8%
[16]
vs. 10.3% in pre-TAVI, concomitant, and post-TAVI, respectively; P = 0.11) .
In current practice, PCI has been carried out at the time of TAVI in the presence of significant coronary
lesions provided that procedural risk does not outweigh the potential benefit [Figure 1]. The final decision