Transcatheter aortic valve implantation (TAVI) has become a first line management option across all risk categories of elderly patients with symptomatic severe aortic stenosis. As the indications of TAVI expand, the age and the surgical risk of patients undergoing TAVI is decreasing making life-time management after TAVI more compelling. After TAVI, patients endure an incremental risk of acute coronary syndromes (ACSs) which have unique mechanisms and management-challenges that are yet to be fully understood. In this report, we review the mechanisms, the natural history, and the management of post-TAVI ACS.