Co-Occurrence of Aortic Stenosis and Coronary Artery Disease: Facing Challenges Before, During, and After Transcatheter Aortic Valve Replacement.

The introduction of transcatheter aortic valve replacement (TAVR) has revolutionized the management of aortic stenosis (AS), leading to significant improvements in patient outcomes. Over time, advancements in device technology have further optimized safety and performance of TAVR. However, as the pool of low-risk patients undergoing TAVR expands, many of whom present with concomitant coronary artery disease (CAD), new challenges have emerged. A large proportion of TAVR candidates suffer from CAD, and the clinical implications of this comorbidity remain a subject of debate. Research on the relationship between AS and CAD has yielded conflicting results, but severe CAD is generally linked to worse outcomes in AS patients. The coexistence of AS and CAD complicates diagnosis and management, requiring a comprehensive understanding of both invasive and non-invasive diagnostic techniques, along with careful revascularization strategies. This review explores the prevalence, clinical impact, and diagnostic challenges of CAD in TAVR patients, highlighting emerging methods for its assessment. Key aspects of treatment, including the timing of coronary revascularization, coronary re-access after TAVR in different settings, as well as practical tips and tricks for coronary cannulation, are also discussed. The complexity of managing AS and CAD is further intensified by the need for individualized approaches, particularly in hybrid procedures and subsequent TAVR interventions. Ongoing research and technological innovations offer promising solutions for refining the management of CAD in AS patients undergoing TAVR, with an emphasis on improving prognostic accuracy, optimizing revascularization strategies, and enhancing post-procedural care.