Timing of percutaneous coronary intervention in patients undergoing transcatheter aortic valve implantation: A retrospective propensity-matched survival and safety analysis.

BACKGROUND

The coexistence of severe aortic stenosis and coronary artery disease (CAD) in patients undergoing transcatheter aortic valve implantation (TAVI) is a common and clinically significant scenario. However, the optimal timing of percutaneous coronary intervention (PCI) in this population remains an unresolved question. This study aimed to compare the outcomes of patients undergoing PCI either prior to (Pre-TAVI) or simultaneously with (Simultaneous PCI-TAVI) transfemoral TAVI.

METHODS

We retrospectively analyzed consecutive patients with severe symptomatic aortic stenosis and significant CAD who underwent transfemoral TAVI at the Interbalkan Medical Center between January 2019 and December 2024. We included 212 patients, that were categorized into two groups based on the timing of PCI: Pre-TAVI PCI and Simultaneous PCI-TAVI. A 1:1 propensity score matching (PSM) was performed based on baseline clinical and anatomical characteristics, yielding 50 matched pairs. The primary outcome was all-cause mortality at 3 years. Secondary endpoints, adjudicated per VARC-3, included in-hospital mortality, bleeding (types 1-4), major vascular complications, stroke, myocardial infarction, and unplanned rehospitalization. Transfusion ≥2 units was assessed separately as a safety/resource-use endpoint. Survival was analyzed using Kaplan-Meier and restricted mean survival time (RMST). Logistic regression was used for in-hospital composite safety events, and landmark/sensitivity analyses explored the impact of bleeding and transfusion.

RESULTS

In-hospital mortality was low and comparable between groups (4.1 % vs. 2.6 % in the unmatched cohort, p = 0.62; 4.0 % vs. 2.0 % in matched pairs, p = 1.00). Simultaneous PCI-TAVI was associated with fewer VARC-3 type 2-4 bleeds (10 % vs. 4 %, p = 0.048), fewer transfusions ≥2 units (26 % vs. 12 %, p = 0.014), and numerically fewer major vascular complications. At 3 years, RMST analysis demonstrated longer survival with Simultaneous PCI-TAVI: +75 days in the unmatched cohort (95 % CI 10-140; p = 0.024) and + 68 days in matched pairs (95 % CI 5-131; p = 0.033). In a discharge-landmark analysis excluding in-hospital deaths, the survival benefit persisted in both cohorts. Logistic regression identified Pre-TAVI PCI as an independent predictor of the in-hospital composite safety endpoint (aOR 2.52, 95 % CI 1.25-5.07; p = 0.010). RMST regression adjusted for bleeding and transfusion confirmed that the survival benefit of Simultaneous PCI-TAVI was not explained solely by peri-procedural complications.

CONCLUSIONS

In patients undergoing transfemoral TAVI with concomitant CAD, a strategy of Simultaneous PCI-TAVI was associated with improved survival and a lower incidence of bleeding, vascular complications, and transfusion needs compared to Pre-TAVI PCI. These findings support a tailored single-session approach in appropriately selected patients and highlight the value of procedural consolidation to minimize risk.