Role of Mechanical Circulatory Support in High-Risk Patients Undergoing Percutaneous Coronary Intervention

The risk of coronary interventions has fallen despite a temporal increase in complexity. However, patients with multiple comorbidities, complex coronary anatomy, and hemodynamic instability who are a high-risk subgroup that need revascularization are not well studied. Our review focuses on the role of mechanical circulatory support (MCS) in high-risk percutaneous coronary intervention (HR-PCI). Among the MCS devices, intra-aortic balloon pump (IABP) and Impella have been most studied, albeit with limited randomized controlled trial data. There is no unequivocal evidence of hard clinical benefit with the use of these devices in HR-PCI. Recent large observational studies have shown a signal of harm with current usage patterns in the USA with wide variation in the use of MCS devices among people undergoing percutaneous coronary intervention (PCI). Better defining which patients will obtain a net clinical benefit from MCS-supported PCI is required. Optimal patient and proper device selection is of paramount importance to achieve the best outcomes. The use of MCS devices in percutaneous coronary intervention (PCI) should largely be reserved for patients with high SYNTAX scores and EF < 30% that will undergo treatment of longer lengths of disease with atherectomy or have an anticipated long treatment duration and importantly also have a low risk of harm from large bore access for MCS implantation.