Prepared by: Dr. Sefa Sarı

There is no clinical evidence to support the treatment of coronary artery disease (CAD) in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI). The optimal timing for physiology or anatomy -guided coronary intervention has yet to be determined.

FAITAVI is a nationwide, prospective, open-label, multicentre, randomised controlled trial comparing an angiography-guided versus a physiology-guided coronary revascularisation strategy in patients with combined coronary artery disease (CAD) and severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI). The primary endpoint of the study was the occurrence of major adverse cardiac and cerebrovascular events (MACCE), including all-cause death, myocardial infarction, target vessel revascularisation due to ischaemia, disabling stroke, or major bleeding, at the 12-month follow-up.

Patients are divided into two groups: angiography-guided revascularisation and physiology-guided revascularisation. In the angiography-guided group, stenosis of more than 50% will be diagnosed, while in the physiology-guided group, severe coronary artery disease (CAD) will be diagnosed based on FFR and iFR values. In the angiography group, percutaneous coronary intervention (PCI) will be performed before, during or within one month after the TAVI procedure, at the operator's discretion. In the physiology group, FFR and iFR will be performed before the TAVI procedure. If FFR is ≤0.80, PCI will be indicated; otherwise, the intervention will be postponed. If borderline values are observed (0.81–0.85), FFR and iFR will be repeated after TAVI, with PCI performed if necessary.

FFR-guided PCI was associated with a lower MACCE rate at the 12-month follow-up in patients with moderate CAD undergoing TAVI. The primary endpoint occurred in 14 patients (8.5%) in the FFR-guided PCI group and in 25 patients (16.0%) in the angiography-guided PCI group. This difference was primarily due to lower rates of death from any cause and target vessel revascularisation due to ischaemia.

This first study compared FFR-guided PCI with angiography-guided PCI in patients with moderate CAD and severe symptomatic AS undergoing TAVI. FFR-guided PCI was associated with a lower MACCE rate at the 12-month follow-up.

As more than 50% of patients undergoing TAVI have CAD, this study is of interest because it highlights the clinical challenges of managing a coexisting coronary lesion detected during the diagnostic evaluation for a valve intervention. The FAITAVI study focused on moderate coronary lesions, while angiographically severe lesions (DS >90%) were excluded. Furthermore, the study compared angiography with physiology-based guidance and did not include a conservative treatment arm. The study hypothesised that managing coronary lesions according to their functional significance could inform the decision-making process for TAVI candidates with stable CAD. It also emphasised the potential advantages of FFR-guided PCI in patients undergoing complex interventions, including TAVI. This study provides data that could influence the clinical decision-making process for patients with moderate coronary stenosis who are candidates for TAVI. Further research is needed to better understand the impact of functionally guided revascularisation on TAVI patients and its potential advantages over conservative treatment.