TAVI patients with bystander coronary artery disease should receive PCI: pros and cons

The coexistence of coronary artery disease (CAD) and severe aortic stenosis is a frequent and complex clinical scenario, affecting up to 80% of patients undergoing transcatheter aortic valve implantation (TAVI). As the profile of TAVI candidates evolves − with younger patients and longer life expectancies − the prognostic implications of CAD become increasingly relevant. In addition, while aortic stenosis is a life-threatening condition requiring treatment to reduce overall mortality, the management of concomitant CAD is also crucial to improve symptoms. Treating significant CAD may undermine the benefits of TAVI, leading to persistent angina, adverse cardiac events over time, and reduced quality of life. However, stable CAD rarely necessitates urgent intervention, and percutaneous coronary intervention (PCI) carries potential risks (including bleeding, stroke, and acute kidney injury) without clear benefits in this setting. Although two randomised trials investigated this delicate issue, whether treating bystander CAD in patients undergoing TAVI is associated with favourable prognostic implications or merely adds procedural risks remains a matter of debate.