THE TCW trial has demonstrated that fractional flow reserve (FFR)-guided percutaneous PCI plus TAVI is superior to SAVR plus CABG in treating patients with severe aortic stenosis and complex coronary artery disease, with significantly lower rates of all-cause mortality and life-threatening bleeding.
Patients with severe aortic stenosis frequently present with obstructive coronary artery disease, with surgical aortic valve replacement (SAVR) and coronary artery bypass grafting (CABG) traditionally considered the gold standard for treatment. This international, multicentre randomised controlled trial aimed to assess whether FFR-guided PCI plus TAVI, a less invasive alternative, was non-inferior to SAVR plus CABG. Conducted at 18 tertiary centres across Europe, the study enrolled 172 patients aged 70 or older with severe aortic stenosis and complex coronary artery disease.
Patients were randomly assigned to undergo either FFR-guided PCI plus TAVI (91 patients) or SAVR plus CABG (81 patients). The primary endpoint was a composite of mortality, myocardial infarction, stroke, revascularisation, valve reintervention, and major bleeding at one year. The FFR-guided PCI plus TAVI group experienced significantly better outcomes for the primary endpoint (4% vs 23%; risk difference –18.5 [90% CI –27.8 to –9.7]), achieving non-inferiority (p<0.001) and superiority (HR 0.17 [95% CI 0.06–0.51]; p<0.001) compared to SAVR plus CABG. These results were largely driven by lower rates of all-cause mortality (0% vs 10%; p=0.0025) and life-threatening bleeding (2% vs 12%; p=0.010).
The findings of the TCW trial support the use of FFR-guided PCI plus TAVI as a superior alternative to SAVR plus CABG in appropriately selected patients. With lower mortality and bleeding risks, this minimally invasive approach represents a significant advance in the management of severe aortic stenosis and complex coronary artery disease, particularly for elderly and high-risk patients. Future studies should explore long-term outcomes, quality of life, and cost-effectiveness to refine guidelines and inform clinical practice.
Katrina Thornber, EMJ
Reference
Kedhi E et al. TransCatheter aortic valve implantation and fractional flow reserve-guided percutaneous coronary intervention versus conventional surgical aortic valve replacement and coronary bypass grafting for treatment of patients with aortic valve stenosis and multivessel or advanced coronary disease: the transcatheter valve and vessels trial (TCW trial): design and rationale. American Heart Journal. 2024;270:86-94.
