Haemodynamic Support in High-Risk PCI: Device Selection, and Evolving Practice

The role of mechanical circulatory support (MCS) in high-risk percutaneous coronary intervention (PCI) has shifted substantially over the last five years. What was once a binary choice — Impella or VA-ECMO — has evolved into a more nuanced practice in which devices are increasingly used in combination. The most prominent of these strategies, ECPELLA (the concurrent use of VA-ECMO and Impella), allows operators to take on patients with severe coronary disease, reduced ejection fraction, or cardiogenic shock who would previously have been declined for percutaneous treatment.Despite rapid clinical adoption, the evidence base remains uneven. Several fundamental questions are still unresolved in everyday practice: which patients gain the most from MCS, at what point support should be initiated, how devices should be sequenced and weaned, how to balance left ventricular unloading against systemic perfusion, and what the long-term outcomes look like beyond the index procedure. The reporting of major randomised and registry-based studies in this space — including data on protected PCI, ECPELLA configurations, and post-shock recovery pathways — makes this a timely moment to consolidate what is known and surface what is not.This Research Topic aims to bring together evidence and practical insight from the full multidisciplinary team involved in delivering these therapies: interventional cardiologists, cardiac surgeons, cardiac anesthesiologists, intensivists, perfusionists, ECMO specialists, ECMO nurses, critical care nurses, advanced practice providers, and clinical engineers. The perfusionist's perspective is rarely represented in the interventional cardiology literature, yet it is central to how mean arterial pressure (MAP), ventricular unloading, and end-organ perfusion are actually maintained at the bedside. By placing that perspective alongside the interventional and surgical viewpoints, the collection aims to produce a more complete and clinically useful picture of MCS in high-risk PCI than any single discipline could offer alone.The success of contemporary MCS programs depends on close collaboration between physicians, perfusionists, anesthesia teams, ECMO specialists, and critical care nurses. These professionals play essential roles in patient selection, procedural safety, haemodynamic optimization, anticoagulation management, device troubleshooting, recovery, and weaning. Despite this, their perspectives remain underrepresented in the literature and are strongly encouraged within this Research Topic. We welcome contributions including, but not limited to:• Patient selection and risk stratification for high-risk and protected PCI • Device selection and sequencing strategies, including ECPELLA configurations • Optimisation of haemodynamics: MAP targets, ventricular unloading, end-organ perfusion, and tissue oxygen delivery • Anticoagulation management during combined MCS • Cannulation, decannulation, and weaning strategies • Outcomes data from recent randomised trials and registries • Multidisciplinary team models and the roles of perfusionists, cardiac anesthesiologists, ECMO specialists, and nursing professionals in MCS delivery • Long-term cardiac and functional outcomes following high-risk PCI with MCS • Peri-procedural anesthetic management during high-risk PCI and ECPELLA • Echocardiographic and haemodynamic monitoring during MCS-supported PCI • ECMO specialist and nursing perspectives in MCS delivery • Complications of combined MCS, including bleeding, thrombosis, limb ischemia, haemolysis, stroke, and acute kidney injury • Escalation, de-escalation, and protocolized weaning strategies • Transition between support modalities (Impella, VA-ECMO, ECPELLA, RVAD, and durable MCS) • Bridge-to-recovery, bridge-to-decision, bridge-to-transplant, and bridge-to-LVAD strategies • Shock team activation, multidisciplinary decision-making, and institutional protocol development • Simulation training, human factors, and team communication in MCS programs • Resource utilization, cost-effectiveness, and healthcare system considerations • Emerging technologies and future directions in temporary mechanical circulatory support • Quality improvement initiatives, registries, and real-world experiences in high-risk PCI and cardiogenic shock programs Topic editors: Salman Butt, Mitesh Badiwala, Habib Khan Source: https://www.frontiersin.org/research-topics/84277/haemodynamic-support-in-high-risk-pci-device-selection-and-evolving-practice