Clinical Outcomes of Transcatheter Versus Surgical Management of Coronary Artery Disease and Aortic Stenosis

The coexistence of severe aortic stenosis (AS) and coronary artery disease (CAD) represents one of the most difficult challenges for the Heart Team. Surgical aortic valve replacement (SAVR) with concomitant coronary artery bypass grafting (CABG) has been the reference strategy. However, with the expanding indications for transcatheter aortic valve replacement (TAVR) and the increasing feasibility of percutaneous coronary intervention (PCI), the combined PCI–TAVR strategy has emerged as a less-invasive alternative option. Whether this approach presents comparable outcomes to CABG–SAVR remains uncertain. This systematic review and meta-analysis were conducted in accordance with the updated PRISMA 2020 guidelines [1]. The rationale and design of our project were prospectively registered in the PROSPERO database (CRD42025630603). A systematic search of the PubMed, Cochrane, and Scopus databases was conducted to identify relevant studies that reported distinct short-term outcomes for patients undergoing PCI-TAVR versus CABG-SAVR, published up to January 15, 2025. We performed a meta-analysis of nine studies (seven observational; two randomized), including 136,763 patients (PCI–TAVR: 101,529; CABG–SAVR: 35,234). The primary endpoints were 30-day all-cause mortality and stroke, and secondary endpoints included acute kidney injury (AKI), permanent pacemaker implantation (PPI), and major vascular complications. Our meta-analysis showed that 30-day mortality was comparable between the two groups (RR: 0.83, 95% CI: 0.61–1.14). However, sensitivity analysis showed that exclusion of the large registry by Patlolla et al. shifted the results toward a survival benefit with PCI–TAVR (RR: 0.66, 95% CI: 0.54–0.81) [2]. Stroke rates were numerically lower, but borderline statistically significant, and AKI rates were significantly lower in the PCI–TAVR group (RR: 0.85, 95% CI: 0.73–1.00, and RR: 0.56, 95% CI: 0.36–0.88, respectively). Notably, PCI–TAVR was associated with significantly higher rates of new PPI (RR: 2.05, 95% CI: 1.87–2.25). No significant difference was observed in major vascular complications between groups (Figure 1). No significant differences between the two groups in 30-day mortality and major vascular complications. Significantly lower rates of AKI and stroke rates in the PCI-TAVR group. Significantly higher rates of PPI in PCI–TAVR groups. A previous meta-analysis by Talanas et al. [3] also reported no significant difference in all-cause mortality between TAVR and SAVR (HR: 1.03, 95% CI: 0.95–1.11). However, its sample size was smaller (3985 vs. 3800 patients) and excluded observational studies, providing a less-powered (Central Illustration 1) analysis. Our analysis strengthens these observations by including both randomized and observational evidence across a broader population. Furthermore, the increased need for PPI after TAVR deserves emphasis. Conduction disturbances are strongly linked to the burden of aortic valve and annular calcification. Excessive calcification near the atrioventricular conduction system might compress or injure the His bundle or left bundle branch, increasing the risk of PPI. This mechanism might explain the higher PPI rates observed with PCI–TAVR across studies, in line with the results of Sakurai et al. [4], who confirmed this association in their pooled analysis. Against this background, the use of BEV might be beneficial [5]. According to current European and American guidelines, CABG–SAVR should be preferred for younger patients with complex CAD and a lower surgical risk. However, both European and American guidelines emphasize the Heart Team decision-making and a personalized approach, showing the lack of clear evidence and highlighting the need for further studies on this contemporary topic [6, 7].(Central Illustration 1). Our meta-analysis is the first to include both randomized and real-world observational data, as well as a larger sample, allowing for a broader and more representative perspective. Nonetheless, limitations must be acknowledged. First, high heterogeneity was observed for stroke, AKI, and PPI (I² > 50%), likely reflecting unadjusted confounding and baseline risk imbalances across predominantly observational studies. In addition, baseline surgical risk differed between groups, as expected, indicating that patients in the PCI–TAVR group might be more vulnerable. Furthermore, the follow-up duration was short, and since no trials systematically reported long-term valve durability or coronary re-intervention, our analysis cannot address these outcomes. Finally, given the study-level nature of this meta-analysis and the lack of consistently reported individual-patient data, we were unable to perform subgroup analyses by CAD complexity (e.g., SYNTAX score) or TAVR valve platform (SEV vs. BEV). In conclusion, this meta-analysis suggests that PCI–TAVR is associated with a lower incidence of 30-day stroke compared with CABG–SAVR. However, this effect is borderline statistically significant and should be interpreted as a trend. Additionally, it is associated with lower in-hospital AKI. Meanwhile, 30-day mortality and major vascular complications remain statistically comparable between the two strategies. Future randomized trials with long-term follow-up are essential to establish definitive treatment strategies in this population. The publication of this article in OA mode was financially supported by HEAL-Link. The authors have nothing to report. The authors have nothing to report. The authors declare no conflicts of interest. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.