Prolonga- tion of cardiopulmonary bypass time may increase renal injury, particularly among those with preexisting renal dysfunction. More complex procedures may also pose a particular risk in patients with fragile tissue integrity or general frailty, and the additional dissection that may be required in a reoperative setting may tip the balance away from imposing additional risk by performing con- comitant procedures. 14.1. Evaluation and Management of CAD in Patients With VHD 14.1.1. Management of CAD in Patients Undergoing TAVI Recommendations for Management of CAD in Patients Undergoing TAVI Referenced studies that support the recommendations are summarized in Online Data Supplement 45. COR LOE Recommendations In patients undergoing TAVI, 1) contrast- enhanced coronary CT angiography (in patients with a low pretest probability for CAD) or 2) an invasive coronary angiogram is recommended to assess coronary anatomy and guide revascularization. In patients undergoing TAVI with significant left main or proximal CAD with or without angina, revascularization by PCI before TAVI is In patients with significant AS and significant CAD (luminal reduction >70% diameter, fractional flow reserve <0.8, instantaneous wave-free ratio <0.89) consisting of complex bifurcation left main and/or multivessel CAD with a SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) score >33, SAVR and CABG are reasonable and preferred over TAVI and PCI.3,4 Synopsis CAD is common among patients presenting with AS, particularly the elderly. In the surgical experience, con- comitant revascularization impacts long-term survival in a favorable way and is commonplace, as is preoperative coronary imaging. Similarly, there is an argument to be made for coronary revascularization among patients un- dergoing TAVI, although the effects on late outcomes are less well defined and may not be the same as for SAVR, given the different demographics and comorbid- ities of the TAVI versus SAVR populations. 