Prior percutaneous coronary intervention versus deferral in patients undergoing transcatheter aortic valve implantation: a systematic review and meta-analysis of randomized controlled trials
Emídio Mata, Carla Barbosa, Inês Morais, Sílvia Ribeiro, José Alberto Rodrigues, António Lourenço, Ricardo Fontes-CarvalhoBackground
Coronary artery disease (CAD) is highly prevalent among patients undergoing transcatheter aortic valve implantation (TAVI), yet the optimal management of concomitant coronary lesions remains uncertain. While routine percutaneous coronary intervention (PCI) prior to TAVI may reduce ischemic complications, it may also increase bleeding risk and procedural burden.
Methods
We systematically searched Cochrane Central Register of Controlled Trials, Scopus, and PubMed for randomized controlled trials (RCTs) comparing routine PCI versus PCI deferral in patients undergoing TAVI with CAD. Primary outcomes were all-cause mortality and myocardial infarction. Secondary outcomes included major bleeding, any bleeding, stroke, hospitalizations, and cardiovascular mortality. Random-effects meta-analysis was performed using hazard ratios with 95% confidence intervals (CIs).
Results
Three multicenter RCTs (2021–2026), including 1132 patients (563 PCI deferral, 569 routine PCI), were analyzed. Routine PCI was not associated with differences in all-cause mortality (hazard ratio = 0.88; 95% CI = 0.67–1.17) or myocardial infarction (hazard ratio = 0.84; 95% CI = 0.44–1.58). Similarly, no significant differences were observed in stroke, hospitalizations, or cardiovascular mortality. However, routine PCI was associated with a higher risk of major bleeding (hazard ratio = 1.61; 95% CI = 1.05–2.49) and any bleeding (hazard ratio = 1.96; 95% CI = 1.28–3.00).
Conclusion
In patients undergoing TAVI with concomitant CAD, PCI deferral appears safe and is associated with a significantly lower bleeding risk, without increasing ischemic events. These findings support a deferral approach to coronary revascularization rather than routine PCI prior to TAVI. However, longer-term follow-up is warranted to better define the impact of this strategy on late ischemic outcomes, particularly as TAVI is increasingly performed in younger patients with longer life expectancy.