Percutaneous Coronary Intervention Before Transcatheter Aortic Valve Implantation in Patients With Coronary Artery Disease: A Systematic Review and Meta-Analysis.

Concomitant coronary artery disease affects 40-75% of patients undergoing transcatheter aortic valve implantation (TAVI). Three recent randomized trials yielded conflicting findings: NOTION-3 demonstrated reduced composite events with pre-TAVI percutaneous coronary intervention (PCI), whereas PRO-TAVI showed non-inferiority of PCI deferral with less bleeding; neither demonstrated mortality benefit. No previous meta-analysis combined all 3 trials with observational evidence, applied design-stratified GRADE certainty, or explored cardiovascular mortality heterogeneity. We performed a systematic review and meta-analysis of 16 studies (3 randomized trials, 13 observational cohorts; 8,207 patients). Ten prespecified outcomes were pooled using Mantel-Haenszel random-effects risk ratios (RRs) with 95% confidence intervals (CIs); 30-day all-cause mortality was primary. GRADE certainty was assessed separately for randomized and observational evidence. Prespecified design-based subgroup and leave-one-out sensitivity analyses were performed. Pre-TAVI PCI was not associated with significant differences in 30-day all-cause mortality (RR 1.26, 95% CI 0.90-1.77; I2 = 32%) or 1-year mortality (RR 1.00, 95% CI 0.87-1.15; I2 = 0%). Major bleeding (RR 1.19, 95% CI 0.98-1.44) and major vascular complications (RR 1.48, 95% CI 0.95-2.30) showed borderline non-significant trends favoring PCI deferral (both I2 = 0%). Excluding Griese et al. 2014, the principal driver of harm and heterogeneity, reduced cardiovascular mortality heterogeneity (RR 0.91; I2 = 24%). No significant differences occurred in stroke, myocardial infarction, acute kidney injury, pacemaker implantation, or rehospitalization. Routine pre-TAVI PCI confers no mortality benefit and may increase bleeding and vascular complications; PCI should be individualized according to coronary complexity, lesion significance, and bleeding risk.