For years, the management of coronary artery disease (CAD) in patients undergoing transcatheter aortic valve replacement (TAVR) has been uncertain. With CAD prevalence as high as 81% in this population, the question of when and how to revascularize is critical.
Two landmark trials, NOTION-3 and FAITAVI, now provide clarity. NOTION-3 showed that physiology-guided PCI reduced the risk of death, heart attack, or urgent revascularization by 29% compared to conservative management. FAITAVI demonstrated that fractional flow reserve (FFR)-guided PCI halved major adverse cardiac events compared to angiography alone.
A key takeaway: FFR is preferred over the instantaneous wave-free ratio (iFR) for assessing coronary blockages in severe aortic stenosis, as iFR can overestimate severity and lacks prognostic value.
Valve selection also matters. Self-expanding valves like Medtronic's Evolut pose greater challenges for future coronary access, with cannulation failure rates up to 22 of 23 cases in one study. Balloon-expandable valves like Edwards' SAPIEN 3 offer better access. Commissural alignment techniques, such as the cusp-overlap view, can reduce access failure.
For younger, lower-risk TAVR patients, preserving coronary access is essential. The evidence now supports individualizing treatment with physiology-guided revascularization rather than a one-size-fits-all approach.