Background: The best management of stable coronary artery disease (CAD) in patients undergoing transcatheter aortic valve implantation (TAVI) is still unclear due to the marked inconsistency of the available evidence. Methods: The REVASC-TAVI registry (Management of Myocardial Revascularization in Patients Undergoing Transcatheter Aortic Valve Implantation With Coronary Artery Disease) collected data from 30 centers worldwide on patients undergoing TAVI who had significant, stable CAD at preprocedural work-up. For the purposes of this analysis, patients with either complete or incomplete myocardial revascularization were compared in a propensity score matched analysis, to take into account of baseline confounders. The primary and co-primary outcomes were all-cause death and the composite of all-cause death, stroke, myocardial infarction, and rehospitalization for heart failure, respectively, at 2 years. Results: Among 2407 patients enrolled, 675 pairs of patients achieving complete or incomplete myocardial revascularization were matched. The primary (21.6% versus 18.2%, hazard ratio‚ 0.88 [95% CI, 0.66–1.18]; P =0.38) and co-primary composite (29.0% versus 27.1%, hazard ratio‚ 0.97 [95% CI, 0.76–1.24]; P =0.83) outcome did not differ between patients achieving complete or incomplete myocardial revascularization, respectively. These results were consistent across different prespecified subgroups of patients (< or >75 years of age, Society of Thoracic Surgeons score > or or 0.10). Conclusions: The present analysis of the REVASC-TAVI registry showed that, among TAVI patients with significant stable CAD found during the TAVI work-up, completeness of myocardial revascularization achieved either staged or concomitantly with TAVI was similar to a strategy of incomplete revascularization in reducing the risk of all cause death, as well as the risk of death, stroke, myocardial infarction, and rehospitalization for heart failure at 2 years, regardless of the clinical and anatomical situations.

BACKGROUND: Angiography-derived computational physiology is an appealing alternative to pressure-wire coronary physiology assessment. However, little is known about its reliability in the setting of severe aortic stenosis. This study sought to provide an integrated assessment of epicardial and microvascular coronary circulation by means of single-view angiography-derived physiology in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI). METHODS: Pre-TAVI angiographic projections of 198 stenotic coronary arteries (123 patients) were analyzed by means of Murray’s law-based quantitative flow ratio and angiography microvascular resistance. Wire-based reference measurements were available for comparison: fractional flow reserve (FFR) in all cases, instantaneous wave-free ratio in 148, and index of microvascular resistance in 42 arteries. RESULTS: No difference in terms of the number of ischemia-causing stenoses was detected between FFR ≤0.80 and Murray’s law-based quantitative flow ratio ≤0.80 (19.7% versus 19.2%; P =0.899), while this was significantly higher when instantaneous wave-free ratio ≤0.89 (44.6%; P =0.001) was used. The accuracy of Murray’s law-based quantitative flow ratio ≤0.80 in predicting pre-TAVI FFR ≤0.80 was significantly higher than the accuracy of instantaneous wave-free ratio ≤0.89 (93.4% versus 77.0%; P =0.001), driven by a higher positive predictive value (86.9% versus 50%). Similar findings were observed when considering post-TAVI FFR ≤0.80 as reference. In 82 cases with post-TAVI angiographic projections, Murray’s law-based quantitative flow ratio values remained stable, with a low rate of reclassification of stenosis significance (9.9%), similar to FFR and instantaneous wave-free ratio. Angiography microvascular resistance demonstrated a significant correlation (Rho=0.458; P =0.002) with index of microvascular resistance, showing an area under the curve of 0.887 (95% CI, 0.752–0.964) in predicting index of microvascular resistance ≥25. CONCLUSIONS: Angiography-derived physiology provides a valid, reliable, and systematic assessment of the coronary circulation in a complex scenario, such as severe aortic stenosis.

Background: The impact of staged versus concomitant coronary procedures on renal function in patients with aortic stenosis undergoing transcatheter aortic valve implantation (TAVI) remains unclear. Methods and Results: Three‐hundred thirty‐nine patients undergoing coronary procedures and TAVI as a staged strategy (160, 47.2%) or concomitant strategy (179, 52.8%) were retrospectively analyzed. Contrast‐induced acute kidney injury (CI‐AKI) occurred in 49 patients in the staged strategy group (30.6%) and in 18 patients (10.1%) in the concomitant strategy group ( P <0.001). Among the staged strategy group, 25 (15.6%) patients developed CI‐AKI after coronary angiography or percutaneous coronary intervention, 17 (10.6%) after TAVI, and 7 (4.3%) after both the procedures. Staged strategy was associated with a higher risk of CI‐AKI (odds ratio, 3.948; P <0.001) after adjustment for multiple confounders and regardless of the baseline renal function ( P for interaction=0.4) when compared with the concomitant strategy. At a median follow‐up of 24.0 months (3.0–35.3), CI‐AKI was not associated with sustained renal injury ( P =0.794), irrespective of the adopted strategy. The concomitant strategy did not impact the overall early safety at 30 days follow‐up after TAVI compared to the staged strategy ( P =0.609). Conclusions: Performing coronary procedures with a staged strategy before TAVI was associated with a higher risk of CI‐AKI compared with a concomitant strategy. Moreover, a concomitant strategy did not increase the risk of procedure‐related complications.

Background. Coronary artery disease (CAD) is a common finding among patients undergoing trans-catheter aortic valve implantation (TAVI), who often present severely calcified coronary lesions. Evidence is scarce about the use of rotational atherectomy (RA) in this setting, in particular regarding long-term outcome. Methods. RA was performed on severely calcified coronary lesions concomitant with TAVI in a consecutive series of patients treated between 2010 and 2020. Immediate and long-term clinical outcomes are reported. Results. A concomitant CAD (coronary stenosis visually > 50%) was observed in 402/845 (47.6%) consecutive patients undergoing TAVI at the University Hospital of Verona. Angioplasty was performed in 104 patients (12.3%). Among these, 19 patients (18.3%, 20 coronary arteries), were treated with RA after TAVI: 10 after implantation of a balloon-expandable trans-catheter valve and 9 after a self-expandable valve. All procedures were successful. Hypotension occurred in 3 patients (15.8%), with rapid recovery after the procedure; CI-AKI (contrast-induced acute kidney injury) in 3 patients (15.8%), of which two recovered within discharge. At a median follow-up of 21.5 months (Q1–3: 6–36) event free survival was 83.3%. Only one patient suffered a target vessel failure >2 years after RA. Neither stroke nor peri-procedural infarctions were detected. Conclusions. RA concomitant with TAVI was feasible and safe in patients treated with implantation of either self-expandable, or balloon-expandable trans-catheter aortic valves. Long-term clinical events related to the coronary procedure were extremely infrequent and the survival rate at median follow-up of 21.5 months was 83.3%.

The classical concept of plaque vulnerability, centred on specific morphological features, has failed to deliver reliable risk prediction in clinical practice. Recent evidence highlights the need to redefine coronary vulnerability as a dynamic, patient-specific phenotype shaped by plaque biology, systemic inflammation, and haemodynamic forces. Advanced imaging modalities, artificial intelligence, and circulating biomarkers now enable a multidimensional assessment of this complex phenotype. This integrative approach may offer a more precise framework for risk stratification and personalised prevention in coronary artery disease.

Optical Coherence Tomography (OCT) is a further light-based intravascular imaging modality and provides a high-resolution, cross-sectional view of coronary arteries. It has a useful anatomic and increasingly physiological evaluation in light of coronary artery disease (CAD). This review provides a critical examination of the increased application of the OCT in assessing coronary artery physiology, beyond its initial mainstay application in anatomical imaging. OCT provides precise information on plaque morphology, which can help identify vulnerable plaques, and is most important in informing percutaneous coronary interventions (PCIs), including implanting a stent and optimizing it. The combination of OCT and functional measurements, such as optical flow ratio and OCT-based fractional flow reserve (OCT-FFR), permits a more complete assessment of coronary stenoses, which may provide increased diagnostic accuracy and better revascularization decision-making. The recent developments in OCT technology have also enhanced the accuracy in the measurement of coronary functions. The innovations may support the optimal treatment of patients as they provide more personalized and individualized treatment options; however, it is critical to recognize the limitations of OCT and distinguish between the hypothetical advantages and empirical outcomes. This review evaluates the existing uses, technological solutions, and future trends in OCT-based physiological imaging and evaluation, and explains how such an advancement will be beneficial in the treatment of CAD and gives a fair representation concerning other imaging applications.