How to address the coronaries in TAVI candidates: can the need for revascularization be safely determined by CT angiography only?

Coronary artery disease (CAD) remains one of the most frequent comorbidities among transcatheter aortic valve implantation (TAVI) candidates. Whether routine assessment of CAD by invasive coronary angiography (CA) and eventual peri-procedural percutaneous coronary intervention (PCI) is generally beneficial in TAVI patients has recently been heavily questioned. CA carries significant risks, such as kidney injury, bleeding, and prolonged hospital stay, and may frequently be unnecessary if significant stenoses of the proximal coronary segments can be ruled out on computed tomography angiography. Moreover, the benefits of pre-emptive coronary revascularization at the time of TAVI are not well defined. Despite these facts and weak guideline recommendations, CA and eventual PCI of stable significant coronary lesions at the time of TAVI remain common practice. However, ongoing randomized trials currently challenge the efficacy of such strategies to enable a more streamlined, individualized, and resource-sparing treatment with TAVI.