Mechanical Circulatory Support for High-Risk Percutaneous Coronary Intervention: Is It a Choice or Chance That Determines Outcomes?

Percutaneous coronary intervention (PCI) in high-risk patients based on anatomy (left main disease, multivessel disease, calcification), comorbidities (advanced age, frailty, renal dysfunction, valvular heart disease), and adverse hemodynamics (decreased left ventricle ejection fraction, poor cardiac output, relative hypotension) 1 poses a significant challenge for interventional cardiologists.Although generally well tolerated, alterations in coronary perfusion during PCI in high-risk patients can limit quality and completeness of revascularization, potentially leading to worse short-term and long-term outcomes.Use of mechanical circulatory support (MCS) devices can minimize hemodynamic compromise and enable optimal completion of PCI. 2 In contemporary practice, there are 2 MCS devices that are primarily used and widely available: percutaneous ventricular assist device (PVAD) and intra-aortic balloon pump (IABP).The use of IABP in high-risk PCI has not been shown to improve patient outcomes, 3 and a randomized trial comparing PVAD and IABP for high-risk PCI did not show any differences in short-term outcomes. 4This comparison, however, was not sufficiently powered to examine intermediate-term outcomes and did not account for the learning curve associated with PVAD use, 5 and a per-protocol analysis did show a trend toward reduction in major adverse events at 90 days with the use of PVAD. 6espite limited randomized trial data, IABP is still commonly used, and there has been an increase in the use of PVAD for PCI in high-risk patients in recent years. 3n this issue of JSCAI, Shah et al 7,8 present 2 articles examining the use of PVAD and IABP for high-risk PCI. 7,8In the research letter, 8 the authors highlight limitations in comparing outcomes among patients receiving PVAD-and IABP-supported PCI using observational data.The authors highlight that in real-world use, there is no equipoise in device selection for high-risk PCI.Rather, there appears to be preferential use of PVAD for very high-risk patients and IABP for patients at a relatively lower risk.This is illustrated in the propensity score