Mechanical Circulatory Support in High-Risk Percutaneous Coronary Intervention: Current Evidence, Clinical Applications and Future Research Perspectives

Abstract

Mechanical circulatory support (MCS) has emerged as a critical adjunct in high-risk percutaneous coronary intervention (PCI), offering hemodynamic stabilization in patients with complex coronary anatomy, severe left ventricular dysfunction, or cardiogenic shock. Devices such as the intra-aortic balloon pump, Impella, and veno-arterial extracorporeal membrane oxygenation have expanded the therapeutic options for interventional cardiologists, enabling safer revascularization in patients previously considered unsuitable for PCI. The intra-aortic balloon pump primarily provides afterload reduction and modest cardiac output augmentation, whereas Impella devices offer direct left ventricular unloading with greater hemodynamic support, and veno-arterial extracorporeal membrane oxygenation provides full cardiopulmonary support in refractory shock. Current evidence suggests that contemporary percutaneous MCS devices can improve procedural success and short-term hemodynamic parameters, although randomized trials have produced mixed results regarding mortality and long-term outcomes. Clinical indications vary according to hemodynamic severity, procedural complexity, and institutional expertise, with Impella and extracorporeal membrane oxygenation increasingly favored in profoundly unstable patients, while intra-aortic balloon pump remains widely used in less severe hemodynamic compromise. Clinical applications continue to evolve, with increasing emphasis on patient selection, timing of device deployment, and multidisciplinary heart team decision-making. Despite technological advances, challenges remain, including vascular complications, bleeding risk, device-related infections, and high cost, which limit widespread adoption in low- and middle-income settings. Future research is needed to refine risk stratification models, establish standardized protocols for device use, and evaluate novel MCS technologies with improved safety profiles. Additionally, large-scale randomized controlled trials and real-world registries are essential to clarify the impact of MCS on long-term clinical outcomes and cost-effectiveness. As interventional cardiology advances toward increasingly complex coronary interventions, MCS is poised to play an expanding role in improving procedural safety and patient outcomes.