TAVI-first strategy matches PCI-first approach in landmark heart valve trial

A common problem in cardiology has finally been put to the test. When a patient arrives with a narrowed aortic valve and blocked coronary arteries, both needing treatment, doctors have traditionally reached for one intervention first—coronary stenting, or PCI—and saved the valve replacement for later. But what if the order didn't matter? What if, in some cases, treating the valve first made more sense?

That question drove a multinational team led by Professor Barbara Elisabeth Stähli at the University Hospital Zurich to design and conduct the TAVI PCI trial, results from which were presented at the European Society of Cardiology Congress in 2026 and published simultaneously in the New England Journal of Medicine. The trial enrolled 986 patients across 48 centers in Austria, France, Germany, Italy, the Netherlands, and Switzerland. The average age was 82 years; roughly a third were women. All had severe aortic stenosis—the valve narrowed to the point of dysfunction—and all had coronary artery disease serious enough to warrant intervention. The question was simple: does it matter which procedure comes first?

The researchers randomized patients into two groups. One group received TAVI, the minimally invasive transcatheter aortic valve implantation, followed by angiography-guided PCI. The other received PCI first, then TAVI. Both procedures were completed within 45 days of each other. The primary endpoint was a composite measure: death from any cause, nonfatal heart attack, need for additional revascularization, hospitalization related to the valve or heart failure, or major bleeding within one year.

The results showed no meaningful difference between the two approaches. In the TAVI-first group, the primary endpoint occurred in 22.2 percent of patients. In the PCI-first group, it occurred in 24.2 percent—a difference of two percentage points that fell well within the margin of statistical noise. The trial was designed to test noninferiority, and TAVI-first cleared that bar decisively. Breaking down the individual components of the primary endpoint revealed no significant divergence between groups. The safety profile also favored the TAVI-first approach: major bleeding occurred in 6.6 percent of TAVI-first patients versus 9.7 percent of those treated with PCI first.

One finding stood out as particularly interesting. Fewer patients in the TAVI-first group ultimately underwent PCI than expected. This was not because the valve replacement somehow blocked access to the coronary arteries. Rather, once the aortic valve had been treated and the heart's function improved, the clinical calculus around whether PCI was still necessary sometimes shifted. A patient who appeared to need both interventions at the outset might, after the valve was fixed, no longer require coronary stenting. This observation hints at a deeper truth: the order of treatment can influence which treatments end up being necessary at all.

Stähli emphasized the practical implications. "The results demonstrate that we as clinicians now have a choice," she said. The trial provides randomized evidence to guide individualized decision-making rather than defaulting to protocol. For some patients, treating the coronary arteries first remains the right call. For others, the valve should come first. The decision should rest on a patient's symptoms, anatomy, bleeding risk, the extent and location of coronary disease, and the overall clinical picture. What had been a settled question—PCI first, always—is now genuinely open. The trial suggests that cardiologists can tailor the sequence to each patient's circumstances rather than following a one-size-fits-all algorithm. The findings also raise questions for future research: how do antiplatelet medications and the timing between procedures influence bleeding risk? These remain to be answered, but the TAVI PCI trial has already shifted the ground beneath a standard practice.