Key takeaways
Many patients who have narrowed aortic valves also have diseased coronary arteries.
The preferred treatment strategy when both transcatheter aortic valve implantation (TAVI) and percutaneous coronary intervention (PCI) are planned has not been investigated in a randomised trial.
Results from a large trial established that a TAVI-first strategy was noninferior to a PCI-first strategy at one year.
The investigators concluded that, based on this randomised evidence, the treatment strategy can now be individualised according to what is best for each patient.
Munich, Germany – 30 August 2026: A TAVI-first strategy was noninferior to a PCI-first strategy after one years' follow-up, according to results presented in a Hot Line session today at ESC Congress 20261 and published simultaneously in the New England Journal of Medicine.
In patients with aortic stenosis, the heart's aortic valve narrows and no longer opens properly. Surgery may be used to replace the aortic valve, but the minimally invasive procedure, transcatheter aortic valve implantation (TAVI), is increasingly being used. Additionally, as explained by Professor Barbara Elisabeth Stähli from the University Hospital Zurich, Switzerland, many patients scheduled for TAVI also need another heart procedure: "About half of patients undergoing TAVI also have coronary artery disease, and approximately 10 to 20% are treated with percutaneous coronary intervention (PCI). In practice, most patients undergo PCI first and then have TAVI later." However, she noted that performing TAVI first then PCI can have advantages for some patients, for example, due to the medications needed after PCI. "Despite being a common clinical scenario, the preferred treatment strategy of PCI and TAVI has not been evaluated in a randomised trial, and we designed the TAVI PCI trial to answer this important question," she said.
Professor Stähli and colleagues conducted an open-label, randomised, noninferiority trial at 48 centres in Austria, France, Germany, Italy, the Netherlands and Switzerland. Patients with severe aortic stenosis and concomitant coronary artery disease deemed eligible for both TAVI and PCI by a multidisciplinary heart team were randomised (1:1) to either TAVI followed by angiography-guided PCI (TAVI-first group) or angiography-guided PCI followed by TAVI (PCI-first group), with both procedures completed between 1 and 45 days of each other. The primary endpoint was a composite of all-cause death, nonfatal myocardial infarction, ischaemia-driven revascularisation, valve-, procedure- or heart failure-related rehospitalisation or life-threatening, disabling or major bleeding at one year. The study population included 986 patients, with a mean age of 82 years, and 34% were women.
The researchers found that the TAVI-first strategy was noninferior to the PCI-first strategy at one year. The primary endpoint occurred in 22.2% of patients in the TAVI-first group and 24.2% in the PCI-first group (risk difference −2.0 percentage points; 95% confidence interval −7.4 to 3.4; p for noninferiority <0.001). There was no evidence of treatment heterogeneity across prespecified subgroups, for example, by age, sex and complexity of PCI.
The individual components of the primary endpoint were generally similar between the two groups. "An interesting observation was that fewer patients in the TAVI-first group ultimately underwent PCI. Importantly, this was not because coronary access was impaired after TAVI. Rather, once the valve had been treated, the clinical decision about whether PCI was still necessary sometimes changed," reported Professor Stähli.
Regarding safety, life-threatening, disabling or major bleeding occurred in 6.6% of patients in the TAVI-first group and 9.7% in the PCI-first group. "BARC type 3a bleeding appeared to be less frequent with the TAVI-first strategy, although this secondary finding should be interpreted cautiously. Antiplatelet therapy and the interval between the two procedures may play a role, and these questions need further study," noted Professor Stähli.
Discussing the implications of these findings, Professor Stähli said: "The results of the TAVI PCI trial demonstrate that we as clinicians now have a choice. The trial provides randomised evidence to individualise the treatment strategy according to what is best for each patient. In patients for whom both TAVI and PCI were planned, a TAVI-first strategy was noninferior to a PCI-first strategy at one year. PCI therefore does not necessarily have to come first. For some patients, there may be good reasons to treat the coronary arteries first. For others, treating the valve first may make more sense. Symptoms, anatomy, bleeding risk, coronary disease and the overall clinical situation all matter," she concluded.
