Background: In elderly patients with severe aortic stenosis (AS), concomitant coronary artery disease (CAD) is common. Escpecially for intermediate-risk patients eligible for both interventional and surgical treatment, long-term benefit of either approach remains unclear. Objectives: To compare long-term outcomes of TAVI + PCI versus SAVR + CABG in intermediate-risk AS-CAD patients (logistic EuroSCORE 10–20%, EuroSCORE II 4–9%). Methods: This retrospective multicentre study included 366 patients treated between 2012 and 2020: 211 underwent TAVI + PCI and 155 received SAVR + CABG. The primary endpoint was all-cause mortality up to three years; secondary outcomes followed VARC-3 criteria. Results: Mortality rates were similar at 30 days (4.8% vs. 8.4%, p = 0.16), six months (12.4% each), one year (18.1% vs. 15.7%) and two years (24.9% vs. 20.1%). At three years, mortality was higher after TAVI + PCI (37.1% vs. 25.5%, p = 0.02), though CAD complexity was greater in the SAVR + CABG group (SYNTAX Score 22.2 vs. 15.9, p < 0.001). TAVI + PCI patients were older (81.1 vs. 78.5 years, p < 0.001), but surgical risk was comparable (EuroSCORE II 6.4% vs. 6.2%). Surgical patients experienced more complications, including delirium, stroke, acute kidney injury, major bleedings and transfusion needs. After propensity score matching (154 patients per group), 3-year mortality no longer differed significantly (33.8% vs. 25.9%, p = 0.14). Conclusion: Both TAVI + PCI and SAVR + CABG yield comparable long-term outcomes in intermediate-risk AS-CAD patients. Although early complications were more common with surgery, there was a trend towards improved long-term survival.

Background: Pericardial effusion is a common finding on pre-procedural computed tomography (CT) in patients undergoing transcatheter aortic valve implantation (TAVI). However, its clinical significance remains uncertain. Using artificial intelligence (AI)-based image analysis, we sought to determine whether pericardial effusion represents an incidental imaging finding, a marker of hemodynamic burden, or a prognostically relevant phenotype. Methods: This retrospective single-center study included 470 consecutive patients undergoing TAVI for severe aortic stenosis. Pericardial effusion volume was quantified using an AI-based CT segmentation workflow and categorized as no effusion (0 mL), trace effusion (>0–<5 mL), small effusion (5–<30 mL), or larger effusion (≥30 mL). Associations with baseline clinical and echocardiographic characteristics were assessed. Long-term mortality was evaluated using Kaplan–Meier analysis, Cox regression models, and restricted cubic spline analyses. Results: Detectable pericardial effusion was present in 276 patients (58.7%), although larger effusions were uncommon (5.1%). Increasing pericardial effusion volume was associated with a higher prevalence of atrial fibrillation (p = 0.001), higher systolic pulmonary artery pressure (p = 0.004), and lower TAPSE/sPAP ratios (p = 0.007). In contrast, left ventricular ejection fraction and transvalvular gradients did not differ across effusion categories. During long-term follow-up, no significant differences in mortality were observed between pericardial effusion groups (log-rank p = 0.46). Pericardial effusion volume was not associated with mortality when analyzed as a continuous variable (HR 1.00, 95% CI 0.996–1.01; p = 0.842), after logarithmic transformation (adjusted HR 0.91, 95% CI 0.76–1.08; p = 0.293), or in restricted cubic spline analyses. Conclusions: AI-derived pericardial effusion volume identifies a hemodynamic phenotype characterized by atrial fibrillation, pulmonary hypertension, and impaired right ventricular–pulmonary arterial coupling. Despite these associations, pericardial effusion volume does not independently predict long-term mortality after TAVI, suggesting that it reflects cardiovascular congestion and remodeling rather than a prognostically relevant phenotype.