Routine PCI in TAVI candidates cut ischaemic events but raised bleeding

Design

Systematic review, pairwise and network meta-analysis of randomised trials

Population

1476 patients with severe aortic stenosis and coronary disease referred for TAVI

Primary outcome

Major adverse cardiovascular events (study-defined)

Effect

RR 0.80 (95% CI 0.65-0.98); major bleeding RR 1.57 (1.07-2.32)

A meta-analysis in EuroIntervention pooled randomised trials of patients with severe aortic stenosis and coronary artery disease referred for transcatheter aortic valve implantation (TAVI). Five trials (1644 patients) were reviewed and four (1476) pooled, comparing routine percutaneous coronary intervention (PCI) with conservative management.

Routine PCI was associated with fewer major adverse cardiovascular events (RR 0.80, 95% CI 0.65 to 0.98) and much less unplanned revascularisation (RR 0.30). Major bleeding was more common (RR 1.57, 95% CI 1.07 to 2.32). In a network meta-analysis, physiology-guided PCI ranked highest for ischaemic outcomes.

This challenges a recent drift towards leaving coronary disease alone in TAVI patients. The trade-off is real, though: extra antithrombotic therapy and procedures in an older, frail population bring bleeding.

The practical reading is that significant proximal disease in a TAVI candidate deserves treatment, preferably guided by physiology, with antithrombotic therapy kept as short as safety allows. With only four pooled trials and composite endpoints that differed between studies, the heart team still decides case by case.

• Discuss revascularisation of significant coronary disease in every TAVI candidate at the heart team
• Prefer physiology (FFR or iFR) over angiography alone to decide which lesions to treat
• Weigh bleeding risk explicitly, especially in frail patients or those on anticoagulants
• Keep dual antiplatelet therapy after PCI as short as the stent and risk profile allow

Why it matters

It pushes back against the habit of leaving coronary disease untreated at TAVI.

Don't overread it

The physiology-guided ranking comes from an indirect network comparison, not head-to-head trials.

The statistics, in plain English

An RR of 0.80 means about a fifth fewer major events, but the upper confidence limit of 0.98 sits close to no effect, so the benefit could be small. The bleeding increase of about half is just as statistically secure, so both sides of the trade-off need weighing.

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