How should the extent of coronary artery disease influence revascularization decisions in patients undergoing transcatheter aortic valve replacement (TAVR)? A new PRO-TAVI substudy examines this question using baseline SYNTAX scores in 466 randomized patients. Its central finding is a tradeoff: deferring percutaneous coronary intervention (PCI) reduced bleeding, while the subgroup with the greatest coronary disease burden showed a signal favoring PCI before TAVR for a composite of death, myocardial infarction, and stroke.
The distinction between the study’s endpoints is essential. The primary composite, which included major bleeding, did not differ significantly between treatment strategies within the SYNTAX score groups. The signal favoring PCI appeared in a secondary composite that excluded bleeding, within an exploratory subgroup.
Study Design and Population
Broeze and colleagues performed a post hoc, non-prespecified analysis of the PRO-TAVI randomized trial, conducted at 12 centers in the Netherlands. Participants had an indication for TAVR and significant coronary artery disease. They were randomized to PCI before TAVR or initial PCI deferral. Deferral meant that routine PCI was not planned after TAVR; intervention remained available when clinically indicated.
The cohort’s median age was 81 years, and 35.6% were women. Patients with unprotected left main disease, left-main equivalent disease, or a solitary chronic total occlusion were excluded. One-year follow-up was available for 465 of 466 participants.
An independent core laboratory assessed coronary angiograms while blinded to treatment allocation and outcomes. Investigators divided baseline SYNTAX scores into four cohort-specific groups: ≤5 (120 patients), >5 to ≤10 (128), >10 to ≤17 (109), and >17 (109). Clinical endpoints were independently adjudicated. The parent trial’s randomization was stratified by proximal left anterior descending artery disease, rather than by these SYNTAX quartiles.
Key Results at One Year
| Outcome | PCI deferral | PCI before TAVR | Interpretation |
|---|---|---|---|
| Primary composite: death, MI, stroke, or major bleeding | No significant treatment difference within any SYNTAX group | No demonstrated net clinical advantage within these exploratory strata | |
| Death, MI, or stroke; SYNTAX >17 | 17/55 (30.9%) | 8/54 (14.8%) | Adjusted HR 2.43 for deferral vs PCI; 95% CI 1.04–5.64; P=.04 |
| Any bleeding; SYNTAX >17 | 8/55 (14.5%) | 26/54 (48.1%) | Less bleeding with deferral |
| Major bleeding; SYNTAX ≤5 | 3/58 (5.2%) | 13/62 (21.0%) | Adjusted HR 0.23; 95% CI 0.06–0.79; P=.02 |
MI: myocardial infarction; HR: hazard ratio. The secondary “ischemic composite” included all-cause death, not solely cardiovascular death. Hazard ratios were adjusted for STS predicted risk of mortality.
Coronary complexity and the ischemic signal
Among patients with SYNTAX scores >17, the secondary composite occurred more frequently with PCI deferral. The difference was driven mainly by all-cause mortality and stroke rather than myocardial infarction. Death occurred in 10 versus 6 patients, a difference that was not statistically significant individually; stroke occurred in 6 versus 0 patients. These small event counts warrant caution when interpreting the composite.
No significant difference in this secondary composite was observed in the other three SYNTAX groups. A significant result in one subgroup does not, by itself, establish that treatment effects truly differ across subgroups. Furthermore, >17 was this cohort’s upper-quartile boundary, not a validated clinical threshold for choosing PCI.
Bleeding remained an important counterweight
Any bleeding occurred more frequently with PCI before TAVR across all four SYNTAX groups. However, a statistically significant reduction in major bleeding with deferral was demonstrated only in the lowest-score group. These outcomes should not be presented interchangeably.
The authors discuss antithrombotic exposure around PCI and TAVR as a plausible contributor to the bleeding tradeoff. The study does not isolate the causal contribution of individual drug regimens, and it does not establish the optimal timing of PCI for patients who need revascularization.
Relevance to the Heart Team and Perfusion Community
For multidisciplinary valve teams, the analysis highlights the importance of considering coronary anatomy alongside bleeding risk when discussing PCI around TAVR. Coronary disease burden may help frame those discussions, but the findings do not support an automatic intervention rule based on a score of 17.
For perfusion professionals, this is contextual evidence for structural heart care and procedural planning. It does not evaluate cardiopulmonary bypass techniques, mechanical circulatory support strategies, or perfusion-specific outcomes. Its practical contribution is a clearer understanding of the competing risks facing patients referred for transcatheter valve treatment.
Limitations and Evidence Assessment
This was an exploratory analysis, not a prospectively powered comparison within SYNTAX strata. Dividing the population into four groups reduced statistical power, and multiple subgroup comparisons increase the possibility of chance findings. Baseline imbalances may also have influenced the results. Confidence intervals were wide, follow-up was limited to one year, and the exclusions prevent extrapolation to unprotected left main disease.
The randomized parent trial, blinded angiographic assessment, and near-complete follow-up strengthen the evidence. Nevertheless, the subgroup signal requires prospective confirmation. The most defensible interpretation is that PCI deferral reduced bleeding in this selected population, while greater coronary complexity may identify patients who merit closer individualized assessment.
Source and Attribution
This IPA educational summary is adapted from the open-access article by Broeze and colleagues, published under the Creative Commons Attribution 4.0 license. The wording and presentation have been adapted; the cover is a conceptual illustration.
Original Article
Broeze GM, Aarts HM, da Silva Voorham J, et al. Impact of Extent of Coronary Artery Disease in Transcatheter Aortic Valve Replacement: A PRO-TAVI Substudy. JACC: Cardiovascular Interventions. 2026;19:2619–2630. doi:10.1016/j.jcin.2026.07.034.
