Evolution of Coronary Management in the TAVI Era
The management of coronary artery disease (CAD) in patients undergoing transcatheter aortic valve implantation (TAVI) remains one of the most debated topics in interventional cardiology. As TAVI indications expand to younger and lower-risk populations, the long-term impact of concomitant CAD and its optimal revascularization strategy become increasingly critical. Historically, coronary artery disease has been identified in up to 50% of patients presenting for aortic stenosis intervention. However, the elderly and often frail nature of the TAVI population introduces a complex benefit-risk calculation for percutaneous coronary intervention (PCI). While angiography has been the traditional gold standard for identifying coronary stenoses, it is well-recognized that visual assessment often correlates poorly with the functional significance of a lesion, particularly in the context of intermediate-grade stenoses (30-70%). This discrepancy is further magnified in patients with severe aortic stenosis, where altered hemodynamics—such as left ventricular hypertrophy, increased end-diastolic pressure, and microvascular dysfunction—can complicate the interpretation of coronary physiology.
