Management of Coronary Artery Disease in Patients With Severe Aortic Stenosis.

Abstract

The coexistence of severe aortic stenosis (AS) and coronary artery disease (CAD) presents complex diagnostic and therapeutic challenges, particularly as transcatheter aortic valve replacement (TAVR) expands to younger, lower-risk populations. CAD prevalence in AS patients ranges from 27.7% in low-risk cohorts to 74.9% in high-risk populations, synergistically worsening ventricular function and prognosis. Diagnostic evaluation remains challenging due to overlapping symptomatology and altered coronary physiology in severe AS. While invasive coronary angiography remains the gold standard, coronary computed tomography (CT) angiography with CT-derived fractional flow reserve (FFR) shows promise as a non-invasive alternative. Standard FFR thresholds may not be reliable in AS patients, with emerging evidence suggesting AS-specific cutoffs may be needed. Treatment strategies must balance the complexity of CAD with patient risk profiles. Current guidelines recommend bypass surgery with surgical aortic valve replacement for complex multivessel disease, while percutaneous coronary intervention (PCI) with TAVR is preferred for less complex lesions or high-risk patients. The optimal timing of PCI relative to TAVR remains debated, with recent data favoring a "TAVR-first" approach for non-critical lesions. As TAVR extends to younger patients, lifetime management considerations become paramount, including valve durability, future coronary access, and planning for potential re-interventions. Commissural alignment techniques during TAVR are crucial for preserving future coronary access. A multidisciplinary Heart Team approach with robust shared decision-making is essential for optimizing individualized care in this evolving field.