PCI Before or After TAVR?
PCI should be performed before TAVR rather than concomitantly or after the procedure, based on the most recent high-quality evidence showing lower mortality, fewer strokes, and reduced vascular complications with staged pre-TAVR PCI. 1
Timing Recommendation
Perform PCI within 90 days before TAVR for patients with significant coronary artery disease. 1 The 2025 analysis of 51,480 patients from the STS/ACC TVT Registry demonstrated that staged PCI before TAVR resulted in:
- Lower 3-year all-cause mortality (38.1% vs 38.8%, p=0.013) compared to concomitant PCI 1
- Lower composite mortality and stroke (42.8% vs 43.5%, p=0.012) compared to concomitant PCI 1
- Significantly fewer major vascular complications (1.4% vs 2%, p=0.003) compared to concomitant PCI 1
Identifying Candidates for Pre-TAVR PCI
Coronary Assessment Requirements
All TAVR candidates require coronary evaluation through either: 2
- Invasive coronary angiography (standard approach) 2
- Contrast-enhanced coronary CT angiography in patients with low pretest probability of CAD 2
Indications for Pre-TAVR Revascularization
Perform PCI before TAVR for: 2
- Significant left main disease (≥50% stenosis) 2
- Proximal coronary artery disease with or without angina 2
- Coronary lesions with ≥70% diameter reduction 2
- Physiologically significant stenoses (FFR <0.8 or iFR <0.89) 2
Exception: Consider SAVR with CABG Instead
For patients with complex bifurcation left main disease and/or multivessel CAD with SYNTAX score >33, surgical AVR with CABG is preferred over TAVR with PCI. 2 This recommendation reflects superior outcomes for complex coronary anatomy managed surgically rather than percutaneously. 2
Practical Implementation
Staged Approach Benefits
Pre-TAVR PCI offers several procedural advantages: 2
- Lower total contrast volume compared to concomitant procedures 2
- Reduced risk of contrast-induced nephropathy 2
- Safer TAVR procedure with revascularized coronaries 2
- Avoids technically challenging post-TAVR PCI 2
Timing Considerations
While the optimal interval between PCI and TAVR remains somewhat controversial, the evidence supports PCI within 90 days before TAVR. 1 The 2017 ACC Expert Consensus acknowledges that the Heart Valve Team should decide on a case-by-case basis using anatomic, clinical, and physiological characteristics, but staged PCI before TAVR represents common clinical practice. 2
Common Pitfalls to Avoid
Do Not Perform Concomitant PCI-TAVR
The 2025 data clearly demonstrates worse outcomes with same-day procedures. 1 Concomitant PCI increases vascular access complications due to larger sheath sizes, prolonged procedure time, and higher contrast loads. 1
Do Not Defer PCI Until After TAVR
Post-TAVR PCI presents technical challenges: 2
- Difficulty engaging coronary ostia with valve prosthesis in place 2
- Risk of valve leaflet damage 2
- Potential for coronary obstruction 2
Only 1.4% of patients in the registry underwent post-TAVR PCI, reflecting the impracticality of this approach. 1
Assess Completeness of Revascularization
Incomplete revascularization independently predicts increased MACCE risk (p=0.014). 3 When performing pre-TAVR PCI, aim for complete revascularization of significant lesions rather than culprit-only intervention. 3
Special Populations
Multivessel Disease
Approximately 50% of TAVR candidates have multivessel disease with mean SYNTAX scores of 12.1±9.1. 3 These patients frequently exhibit complex lesions (B2/C type in 49.9%, calcified in 45.8%, bifurcation in 21.4%). 3 Pre-TAVR PCI in this population is feasible and safe, with low target lesion failure (2.7%) and target vessel failure (3.3%) rates at 2 years. 3
High-Risk Coronary Features
Even patients with unprotected left main disease or SYNTAX score >32 can undergo successful pre-TAVR PCI, with similar MACCE rates compared to lower-risk anatomy (35.9% vs rest of population, p=0.847). 3 However, for SYNTAX scores >33 with complex left main disease, surgical AVR with CABG remains preferred. 2
Evidence Limitations
No randomized controlled trials definitively establish optimal PCI timing relative to TAVR. 2 The ACTIVATION trial questioned routine revascularization but had significant limitations. 4 Current recommendations derive from large registry analyses and expert consensus rather than RCT-level evidence. 2, 1
Despite this limitation, the 2025 propensity-matched analysis of over 51,000 patients provides the strongest available evidence favoring staged pre-TAVR PCI over concomitant or post-TAVR approaches. 1