Mechanical Circulatory Support for Complex High‐Risk Indicated Percutaneous Coronary Intervention: Network Meta‐Analysis of Randomized Trials

Background Mechanical circulatory support (MCS) is increasingly used during complex high‐risk indicated percutaneous coronary intervention, yet whether different support strategies improve clinical outcomes remains uncertain. We sought to compare the efficacy and safety of individual MCS strategies with standard care and with each other at short‐ and long‐term follow‐up. Methods This frequentist random‐effects network meta‐analysis included randomized trials of patients undergoing nonemergent complex high‐risk indicated percutaneous coronary intervention and comparing percutaneous left ventricular assist devices, intra‐aortic balloon pump, venoarterial extracorporeal membrane oxygenation, or standard care. The primary efficacy outcome was major adverse cardiovascular events. Secondary outcomes included death, myocardial infarction, stroke, or repeat revascularization, and periprocedural major adverse events. Results Eight trials (n=1856) were included. At 30 days, no MCS was associated with lower major adverse cardiovascular events compared with standard care, though percutaneous left ventricular assist devices (risk ratio [RR] 0.30, 95% CI 0.10–0.90) and intra‐aortic balloon pump (RR 0.26, 95% CI 0.07–0.90) reduced periprocedural major adverse events. At a weighted mean of 10.8 months, no significant differences in major adverse cardiovascular events were observed with percutaneous left ventricular assist devices (incidence rate ratio 0.79; 95% CI 0.47–1.35), intra‐aortic balloon pump (incidence rate ratio 0.89, 95% CI 0.52–1.54), or venoarterial extracorporeal membrane oxygenation (incidence rate ratio 1.47, 95% CI 0.64–3.40) compared with standard care. Consistently, no MCS strategy reduced death, myocardial infarction, stroke, or repeat revascularization. Conclusions Among patients undergoing complex high‐risk indicated percutaneous coronary intervention, MCS did not improve clinical outcomes, despite fewer periprocedural adverse events with percutaneous left ventricular assist devices and intra‐aortic balloon pump. These findings do not support routine prophylactic use and suggest that MCS should be limited to selected patients.