PRO‑TAVI: Should High‑Risk Patients Undergo PCI Before TAVI?

The PRO‑TAVI trial, presented at ACC.26 and published in The Lancet, shows that in high‑risk older adults with severe aortic stenosis and significant coronary artery disease (CAD), performing PCI before TAVI yields similar 1‑year outcomes to a strategy of TAVI first, with PCI deferred if needed afterward. 

In this Netherlands‑based, open‑label trial, 466 patients (median age 81, 36% women) were randomized 1:1 to PCI‑first (n=233) or deferred‑PCI (n=233), with many carrying substantial CAD burden.

At one year, the composite of death, MI, stroke, or moderate‑to‑severe bleeding occurred in 24% of the deferral group versus 26% of the PCI‑first group (HR 0.89), meeting the prespecified noninferiority threshold with no evidence of superiority for either approach. 

The key difference was in major bleeding, which occurred in 15% of the PCI‑first arm versus 6% of the deferred‑PCI arm, largely because of dual‑antiplatelet therapy after PCI. 

The editorialists note that, in this elderly population, reducing hemorrhagic events is clinically meaningful, but emphasize that PRO‑TAVI should not be read as proof that PCI is unnecessary in all TAVI candidates. 

Instead, the trial supports a more selective, TAVI‑first, PCI‑deferred strategy in intermediate‑ to high‑risk older patients, while reserving upfront PCI for truly high‑risk coronary lesions.

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Checklists for the practicing cardiologist

• For intermediate‑ to high‑risk TAVI patients ≥80 years with hemodynamically significant CAD, a TAVI‑first, PCI‑deferred strategy is noninferior and reduces early bleeding risk; reserve upfront PCI for truly high‑risk lesions or unprotected left‑main disease.

• Use stress testing or invasive FFR/IMR when feasible to triage which obstructive lesions actually need PCI before or after TAVI, rather than treating anatomy alone.

• For patients randomized to PCI‑first, plan PCI before TAVI in a single‑stage fashion if possible, balance ischemic risk against bleed risk, and minimize dual antiplatelet duration when appropriate.

• For defer‑then‑PCI patients, monitor for recurring or worsening angina post‑TAVI and reserve PCI for symptomatic, high‑risk lesions; maintain single antiplatelet therapy in most.

• For younger, low‑risk TAVI patients, recognize that PRO‑TAVI does not apply, and let individual‑level anatomy, ischemia burden, and multidisciplinary discussion guide the timing of PCI versus TAVI rather than a one‑size‑fits‑all algorithm.