Optimal timing for percutaneous coronary intervention in patients undergoing transcatheter aortic valve replacement: A network meta-analysis

Background: The optimal timing for percutaneous coronary intervention (PCI) in patients undergoing transcatheter aortic valve replacement (TAVR) is uncertain. Objectives: To compare different PCI timings in patients with CAD undergoing TAVR. Methods: MEDLINE, Embase, and Cochrane were systematically searched for studies comparing different timings of PCI in patients with aortic stenosis and coronary artery disease (CAD) undergoing TAVR. PCI in a staged procedure to TAVR and PCI concomitantly to TAVR were compared with TAVR alone without PCI. A frequentist random-effects network meta-analysis calculates the odds ratio (OR) with a 95 % confidence interval (CI). Treatments were ranked using P-score analysis. Results: Two randomized controlled trials and 24 observational studies comprising 10,901 patients with aortic stenosis and CAD were included. Compared with PCI and concomitant TAVR, staged PCI was associated with lower rates of stroke (OR 0.54; 95 % CI 0.37-0.78), myocardial infarction (OR 0.54; 95 % CI 0.31-0.91), and all-cause mortality at 30 days (OR 0.62; 95 % CI 0.41-0.95). In addition, a subgroup analysis showed that staged PCI performed after TAVR is associated with the lowest rates of all-cause mortality of all strategies. In P-score analysis, staged PCI presented the highest likelihood of preventing stroke and myocardial infarction. Conclusion: In patients with aortic stenosis and CAD undergoing TAVR, staged PCI is associated with lower rates of stroke, myocardial infarction, and short-term mortality compared with other timings.