The optimal management of patients presenting with the dual burden of severe aortic stenosis (AS) and concomitant coronary artery disease (CAD) is a hotly debated issue in cardiovascular medicine. Historically, surgical aortic valve replacement (SAVR) combined with coronary artery bypass grafting (CABG) has been the preferred standard, offering a single-stage solution grounded in durability, completeness of revascularization, and established long-term outcomes. , Yet this surgical paradigm comes at the cost of substantial invasiveness, bringing higher risks of perioperative morbidity and early mortality. Furthermore, the rapid evolution of transcatheter aortic valve replacement (TAVR) and percutaneous coronary intervention (PCI) has fundamentally reshaped clinical practice and challenged long-standing assumptions regarding optimal care.
In a recent issue of The American Journal of Cardiology , Baudo and colleagues provide a timely meta-analysis of existing comparative evidence by performing a Kaplan–Meier-derived individual patient data meta-analysis of surgical versus percutaneous strategies in patients with concomitant severe AS and CAD. They included 6 studies—4 propensity score-matched (PSM) observational studies, 1 randomized controlled trial (RCT), and 1 RCT sub-study. These studies were published between 2018 and 2025. The authors interrogated the temporal evolution of risk, suggesting a clinically consequential time-dependent crossover in survival that warrants our consideration.
The central finding of this meta-analysis of nearly 2000 patients was that the percutaneous approach (TAVR + PCI) was associated with a statistically significant early survival advantage (to 19 days), but at 73 days, the surgical approach (SAVR + CABG) captured the survival advantage. This temporal pattern suggests that while TAVR + PCI avoids the early risks associated with major cardiac surgery, the long-term durability of the surgical strategy may eventually confer a protective advantage. Importantly, the strength of this finding was solely attributable to the 4 PSM studies. In the RCT (the TCW trial) included, a significant survival advantage was observed for TAVR + PCI at 1 year. In the RCT sub-study (SURTAVI), there was no difference in survival at 2 years between TAVR + PCI and SAVR + CABG. But not all patients are eligible for RCT’s, so it’s possible that in a “real world” population, there could be a long-term advantage for SAVR + CABG in carefully selected patients.
The secondary outcomes reported by Baudo et al. align with this temporal framework. Patients undergoing TAVR + PCI experienced markedly lower rates of postoperative atrial fibrillation, acute kidney injury, and reintervention, complications that strongly influence early recovery, hospital length of stay, and short-term quality of life. , Conversely, the percutaneous approach was associated with substantially higher rates of moderate-to-severe aortic regurgitation, permanent pacemaker implantation, and major vascular complications. Among these, the excess risk of significant aortic regurgitation is particularly notable, as even mild residual regurgitation have been linked to adverse long-term outcomes after TAVR. However, it’s not clear that this is still the clinical reality for current-generation TAVR valves. At 7-year follow-up of the PARTNER 3 trial, in low-risk patients, there were similar rates of at least moderate aortic regurgitation for TAVR (2.4%) and SAVR (1.6%).
Interestingly, the composite outcome of all-cause mortality or stroke initially favored the transcatheter approach, showing a significantly lower event rate compared to the surgical strategy. However, a sensitivity analysis restricted only to randomized controlled trials found no significant difference between the 2 groups. This discrepancy highlights the influence of study design, residual confounding, and patient selection. It also reinforces the reality that the comparative effectiveness of these strategies is not static, but evolves alongside improvements in device technology, procedural technique, and patient selection.
Perhaps the most important contribution of this work lies not in declaring a “winning” strategy, but in reframing how clinicians interpret risk over time. For patients with advanced age, frailty, or limited life expectancy, the early survival advantage and reduced burden of acute complications make TAVR + PCI an appealing and often appropriate choice. In contrast, for younger patients with longer anticipated survival, the mid-term durability signal favoring SAVR + CABG cannot be ignored. In such patients, accepting greater upfront risk may yield meaningful downstream benefits.
As TAVR continues to expand into lower-risk populations, the findings by Baudo et al. serve as a timely reminder that early safety and late efficacy are not interchangeable metrics. This study reinforces the need for individualized, multidisciplinary-driven decision-making that explicitly incorporates life expectancy, anatomic complexity, and patient priorities. It underscores the necessity for future randomized trials designed with sufficient power and follow-up duration to capture time-dependent treatment effects. Until such data emerges, this meta-analysis provides a critical framework for counseling patients on the evolving balance between early gain and late trade-offs in the management of concomitant AS and CAD.
CRediT authorship contribution statement
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