In patients undergoing TAVI, the concomitant presence of coronary artery disease continues to generate debate: whether coronary lesions should be treated before, during, or after valve implantation, or whether a conservative strategy should be maintained when there is no clear evidence of ischemia. Available randomized evidence has shown heterogeneous results. In this context, coronary physiology has emerged as a tool capable of better selecting candidates for PCI and avoiding unnecessary interventions in a population that is often elderly and frail.
Scarsini and colleagues performed an individual patient data (IPD) meta-analysis including four randomized trials: ACTIVATION, FAITAVI, NOTION-3, and TCW. The aim was to evaluate the clinical efficacy and safety of different coronary revascularization strategies in patients with severe aortic stenosis and coronary artery disease undergoing TAVI.
A total of 1,050 patients were included in the final analysis: 694 assigned to PCI and 356 to optimal medical therapy (OMT). Within the PCI arm, 439 patients underwent an FFR-guided strategy and 255 an angiography-guided strategy alone.
The primary endpoint was 1-year MACE, while the co-primary endpoint was NACE, defined as MACE plus major bleeding at one year. Mean age was 83.1 years, and SYNTAX score was low and similar between groups.
Among revascularized patients, PCI was performed before TAVI in 53.9% of cases, concomitantly with TAVI in 35.9%, and after TAVI in 10.2%.
At one-year follow-up, the PCI strategy was associated with a modest reduction in MACE compared with OMT. MACE-free survival was 92% with PCI versus 86% with OMT (HR 0.70; 95% CI 0.49–0.99; p=0.049). This difference was mainly driven by a lower need for subsequent revascularization: 0.7% with PCI versus 4.5% with OMT (HR 0.34; 95% CI 0.14–0.84).
However, subgroup analysis according to revascularization strategy demonstrated that the benefit was not homogeneous. FFR-guided PCI was associated with lower MACE incidence compared with OMT (HR 0.58; 95% CI 0.37–0.91), whereas angiography-guided PCI alone did not show a significant reduction in the primary endpoint (HR 1.14; 95% CI 0.69–1.91).
Similar findings were observed for NACE: the FFR-guided strategy showed lower risk compared with OMT (HR 0.68; 95% CI 0.51–0.90), while the angiography-guided strategy again failed to demonstrate benefit (HR 1.17; 95% CI 0.76–1.80).
Conclusions: Physiological Assessment With FFR May Improve Patient Selection for PCI Before TAVI
In this individual patient data meta-analysis, PCI in patients undergoing TAVI was associated with a reduction in 1-year MACE, mainly driven by a lower need for repeat revascularization. However, the clinical benefit was observed primarily with the FFR-guided strategy, reinforcing the concept that physiological assessment of coronary lesions may better identify patients who truly benefit from coronary revascularization before TAVI.
Presented by Roberto Scarsini during the Major Late-Breaking Trials session at EuroPCR 2026, held from May 19–22, 2026, in Paris.
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