Clarifying the treatment-pathway effects and generalizability of FAITAVI

This commentary refers to ‘Physiology vs angiography-guided percutaneous coronary intervention in transcatheter aortic valve implantation: the FAITAVI trial’, by F. L. Ribichini et al., https://doi.org/10.1093/eurheartj/ehaf974 and the discussion piece ‘Clarifying the treatment-pathway effects and generalizability of FAITAVI’, by F. L. Ribichini et al., https://doi.org/10.1093/eurheartj/ehag367. We congratulate Flavio L. Ribichini et al.1 for delivering the first randomized comparison of physiology- vs angiography-guided percutaneous coronary intervention (PCI) in transcatheter aortic valve implantation (TAVI) candidates and for stimulating discussion on how to tailor revascularization in this frail population.1 However, three aspects of the dataset require further clarification. First, although randomization allocated patients to decision strategies, the substantial difference in actual PCI exposure (91% vs 60%) and the deferral of PCI in 9% of angiography-guided patients may introduce significant cross-over and then dilute the intended comparison. In the absence of a per-protocol analysis for patients who fully adhered to the assigned strategy, and without data on outcomes stratified by PCI timing (staged pre-TAVI vs same-session vs post-TAVI), it remains uncertain whether the observed clinical benefit is directly attributable to physiological lesion selection, or whether it is confounded by differences in procedural burden, periprocedural management, and the effective triage that occurred in practice.