Optimizing revascularization in the high-risk heart: Impella™-facilitated percutaneous coronary intervention in multivessel coronary artery disease with reduced left ventricular ejection fraction and mitral regurgitation

Percutaneous coronary intervention (PCI) is considered for patients at high risk for peri-operative mortality and complications during coronary artery bypass grafting, with further consideration of mechanical circulatory support (MCS) to prevent haemodynamic decompensation in patients with complex coronary artery disease and reduced ventricular function. However, current risk models do not account for crucial factors such as frailty or severity of valvular disease, potentially underestimating surgical risk. As such, the surgeon's clinical judgment may more accurately reflect a given patient's mortality risk. Here, we present a clinical scenario of a frail, inoperable 73-year-old male with mitral regurgitation and reduced left ventricular ejection fraction who underwent successful complex high-risk PCI supported by an Impella™ microaxial flow pump. A multidisciplinary approach was taken in determining the patient's anatomical and clinical risk profile, with consideration of both conventional risk scores as well as the patient's frailty. The multivessel procedure was carefully planned to minimize intra-procedural risk while achieving the most complete and durable revascularization possible. Planned early use of MCS played a central role in maintaining haemodynamic stability during the intervention. The patient recovered without vascular or device-related complications, and at 6 months, demonstrated improved left ventricular ejection fraction to 45%. This scenario highlights the feasibility and safety of this approach when performed in an experienced centre; however additional studies are needed to define optimal patient selection, procedural protocols, and follow-up pathways. Until then, meticulous multidisciplinary evaluation, tailored procedural planning, and rigorous post-procedural care remain the cornerstones of success.