Coronary Revascularization in the Era of TAVR: Timing, Strategy, and Outcomes.

Background: Coronary artery disease (CAD) is prevalent among patients undergoing transcatheter aortic valve replacement (TAVR), complicating clinical decision-making regarding optimal timing of percutaneous coronary intervention (PCI). Despite widespread clinical experience, there is ongoing controversy and limited consensus regarding when PCI, before, during, or after TAVR, offers the best risk-benefit balance. Objective: To synthesize and critically evaluate the current evidence on different PCI timing strategies in patients undergoing TAVR and to identify areas of uncertainty and clinical complexity. Review: Randomized trials, including ACTIVATION and NOTION-3, have yielded mixed findings, highlighting a modest reduction in ischemic events with pre-TAVR PCI but increased procedural bleeding risks. Observational registries (REVASC-TAVI and the National Readmissions Database) have similarly shown that pre- and peri-TAVR PCI strategies carry heightened risks of complications without clear long-term mortality benefits. Recent meta-analyses reinforce these findings, indicating that no PCI timing strategy conclusively outperforms others in reducing long-term mortality. Key considerations such as anatomical complexity, frailty, bleeding risk, and valve type significantly influence optimal PCI timing. Conclusion: Current evidence supports a personalized, patient-centered approach to PCI timing in TAVR candidates, emphasizing careful consideration of individual anatomical and clinical factors rather than a standardized timing protocol. Further research exploring advanced risk stratification, imaging modalities, and long-term clinical outcomes is essential to refine current guidelines and practice.