Background <p>Conduction disturbances, including bundle branch and atrioventricular blocks, are frequent after aortic valve replacement and may require permanent pacemaker implantation (PPI). In patients with concomitant severe aortic stenosis and coronary artery disease, the fully percutaneous approach (TAVR + PCI) has not been sufficiently compared to SAVR + CABG regarding conduction disturbances and long-term outcomes.</p> Method <p>A total of 1,232 patients undergoing either TAVR + PCI or SAVR + CABG between January 2010 and December 2020 were retrospectively evaluated. Propensity score matching (1:1) was performed based on eight baseline variables to reduce confounding. The final matched cohort included 120 patients (60 per group) with comparable demographic profiles and intermediate surgical risk.</p> Results <p>The TAVR + PCI group exhibited significantly higher rates of in-hospital conduction disturbances (26.7% vs. 6.7%; <i>p</i> = 0.006) and early (30-day) permanent pacemaker implantation (PPI) (16.7% vs. 5.0%; <i>p</i> = 0.039; OR, 3.8; 95% CI, 0.01–2.68). During follow-up, a higher incidence of atrioventricular block was observed in the TAVR + PCI group (28% vs. 12%; <i>p</i> = 0.011), accompanied by a non-significant trend toward increased bundle branch blocks (22% vs. 10%; <i>p</i> = 0.132) and late PPI (11.7% vs. 8.3%; sub-HR, 1.42; 95% CI, − 0.90 to 1.60; <i>p</i> = 0.583). Median survival did not differ significantly between groups (5.55 vs. 4.05 years; HR, 0.77; 95% CI, 0.44–1.32; <i>p</i> = 0.312).</p> Conclusion <p>Compared to SAVR + CABG, the TAVR + PCI strategy is associated with a significantly increased risk of early conduction disturbances and PPI. These findings highlight the relevance of conduction system vulnerability in therapeutic decision-making for patients with combined valvular and coronary pathology</p>