Should Coronary Revascularization Precede Transcatheter Aortic Valve Replacement? A Meta-Analysis of Randomized Controlled Trials

Background: In severe aortic stenosis patients undergoing TAVR, whether coexisting coronary disease prompts revascularization and its optimal timing remain unclear. Aim: To evaluate the efficacy and safety of PCI before TAVR compared to deferred PCI in patients with severe aortic stenosis and concomitant coronary artery disease. Methods: We performed a meta-analysis of RCTs. PubMed, Embase, Scopus, CENTRAL, and Web of Science were searched for RCTs comparing PCI before TAVR versus no PCI. HRs with 95% CIs were pooled using random-effects models. Results: Three RCTs (ACTIVATION, NOTION 3, PRO-TAVI) enrolling 1,156 patients (579 PCI, 577 no PCI) were included. Routine PCI before TAVR did not reduce all-cause mortality (HR 0.88, 95% CI 0.67 to 1.17; p=0.38) or cardiovascular death (HR 0.77, 95% CI 0.49 to 1.19; p=0.23). PCI significantly reduced any revascularization (HR 0.24, 95% CI 0.06 to 0.86; p=0.029), and urgent revascularization (HR 0.33, 95% CI 0.12 to 0.87; p=0.025). MI was not significantly reduced with PCI (HR 0.84, 95% CI 0.44 to 1.59; p = 0.59). Stroke showed a borderline trend favoring PCI (HR 0.69, 95% CI 0.46 to 1.04; p=0.073). PCI significantly increased any bleeding (HR 1.96, 95% CI 1.28 to 3.0; p=0.002) and major bleeding (HR 1.88, 95% CI 1.07 to 3.31, p=0.027). Neither AKI nor rehospitalization differed significantly between groups. Leave-one-out sensitivity analyses confirmed the stability of mortality, stroke, and bleeding estimates. Conclusions: Routine PCI before TAVR does not reduce mortality. It lowers urgent revascularization and trends toward less stroke but nearly doubles bleeding. Findings support selective, individualized PCI rather than routine revascularization before TAVR.