Management of Coronary Artery Disease with Severe Aortic Stenosis
For patients with severe aortic stenosis and significant coronary artery disease, perform surgical aortic valve replacement (SAVR) with concomitant coronary artery bypass grafting (CABG) when you have complex left main or multivessel disease with SYNTAX score >33, and use selective percutaneous coronary intervention (PCI) before transcatheter aortic valve implantation (TAVI) for significant left main or proximal CAD in all other cases 1.
Decision Algorithm Based on CAD Complexity
For Surgical Candidates (SAVR):
Perform SAVR + CABG together when:
- Complex bifurcation left main disease is present
- Multivessel CAD with SYNTAX score >33
- Any significant proximal CAD requiring surgical intervention on another valve or ascending aorta 1
This approach is preferred over TAVI + PCI because observational data show favorable outcomes for concomitant CABG and SAVR over SAVR alone in patients with coronary disease 1.
For TAVI Candidates:
Perform PCI before TAVI (not concomitant) when:
- Significant left main disease is present (with or without angina)
- Proximal CAD is identified 1
Critical timing consideration: Combined pre-TAVI and concomitant PCI strategies show significantly higher mortality at 30 days (OR 5.70) and 2 years (OR 4.40) compared to post-TAVI PCI 2. This strongly supports performing PCI as a staged procedure before TAVI rather than during the same session.
Diagnostic Approach
Use invasive coronary angiography as your primary diagnostic tool 3. While coronary CT angiography is emerging as an alternative, invasive assessment remains the gold standard for anatomical evaluation 3, 4.
Physiological Assessment Caveats:
The interpretation of fractional flow reserve (FFR) and non-hyperemic pressure ratios in severe AS is problematic because:
- Severe AS alters coronary hemodynamics
- Changes myocardial oxygen demand
- Affects microvascular function
- Disrupts the balance between resting and hyperemic flow 4
Despite these limitations, use conventional FFR thresholds (≤0.80) for decision-making because prospective outcome data supporting physiology-guided revascularization in TAVI patients are linked to these conventional thresholds, not AS-specific cutoffs 4. Proposed AS-specific thresholds are derived from small observational studies and remain hypothesis-generating 4.
Avoid Routine PCI
Do not perform routine PCI on all coronary lesions before TAVI 3, 5. The evidence increasingly supports a selective approach based on:
- Lesion physiological significance
- CAD complexity
- Procedural timing considerations
- Future coronary access needs 3
Post-Procedure Management
After valve intervention (either SAVR or TAVI with PCI), manage these patients according to standard secondary prevention guidelines 6:
- Aspirin and statin therapy
- ACE inhibitor consideration
- Dual antiplatelet therapy (DAPT) duration per 2021 ACC/AHA/SCAI revascularization guidelines for those undergoing PCI + TAVI 6
Key Pitfalls to Avoid
Do not perform concomitant PCI during TAVI - the mortality data clearly favor staged procedures 2
Do not rely on AS-specific FFR cutoffs - these are not validated for clinical outcomes 4
Do not choose TAVI + PCI for complex multivessel disease - SAVR + CABG is preferred when SYNTAX score >33 1
Do not defer all PCI until after TAVI - significant left main and proximal disease should be addressed before TAVI 1
The evidence base remains limited by lack of large randomized trials, but the guideline recommendations from ACC/AHA provide the clearest framework for decision-making 1. The distinction between identifying physiologically significant lesions and proving that revascularization improves outcomes remains an important knowledge gap 4, but current best practice favors selective revascularization of significant proximal and left main disease in the TAVI population.