Staged Complete Revascularization for Coronary Artery Disease vs Medical Management Alone in Patients With AS Undergoing Transcatheter Aortic Valve Replacement

Inclusion Criteria: \- Symptomatic aortic valve stenosis prior to TAVR (NYHA Functional Class ≥ 2 OR Abnormal exercise test with severe SOB, abnormal BP response, or arrhythmia) AND \- CAD defined as: at least 1 coronary artery lesion of ≥70% visual angiographic diameter stenosis in a native segment ≥2.5 mm in diameter that is not a CTO and is amenable to treatment with PCI AND \- Consensus by the Local Multidisciplinary Heart Team that the patient is suitable for elective transfemoral TAVR with a balloon expandable transcatheter heart valve AND would receive a bypass with an anastomosis distal to the coronary artery lesion(s) if they were undergoing SAVR. Local Multidisciplinary Heart Teams are expected to follow current clinical guidelines for selection of patients for TAVR with an eligible patient generally expected to have: \[AVA ≤ 1.0 cm2 OR AVA index ≤ 0.6 cm2/m2\] OR \[Jet velocity ≥ 4.0 m/s OR mean gradient ≥ 40 mmHg\] OR patients without these criteria may undergo TAVR if the Local Multidisciplinary Heart Team concludes it is appropriate. AND \- Successful transfemoral TAVR, defined as the implantation of a single transcatheter aortic valve within the past 96 hours with freedom from more than minimal aortic insufficiency, stroke, or major vascular complications. Exclusion Criteria: * PCI already performed within 90 days prior to TAVR or at the same time as the index transfemoral TAVR procedure * Planned PCI of coronary artery lesion(s) * Planned surgical revascularization of coronary artery lesion(s) * Non-cardiovascular co-morbidity reducing life expectancy to \< 5 years * Any factor precluding 5-year follow-up * Prior coronary artery bypass grafting surgery or surgical valve replacement * Severe mitral regurgitation (\> 3+) * Severe left ventricular dysfunction (LVEF \< 30%) * Low coronary takeoff (high risk for coronary obstruction) * Acute myocardial infarction within 90 days * Stroke or transient ischemic attack within 90 days * Renal insufficiency (eGFR \< 30 ml/min) and/or renal replacement Rx * Hemodynamic or respiratory instability