Abstract Patients with advanced coronary artery disease (CAD), severely reduced left ventricular (LV) ejection fraction, and prior coronary artery bypass grafting (CABG) present with complex revascularisation challenges requiring individualised, multidisciplinary decision-making, and pre-procedural strategy planning. Protected percutaneous coronary intervention (PCI) using percutaneous temporary mechanical circulatory support, such as the Impella™ micro-axial flow pump, may enable complex revascularisation in carefully selected patients at high risk of periprocedural haemodynamic compromise. We describe a male patient with advanced ischaemic cardiomyopathy, severe functional mitral regurgitation, and complex multivessel CAD, including chronic total occlusion (CTO) of the left anterior descending artery, following prior CABG. After Heart Team discussion and in the context of prohibitive surgical risk, a staged strategy was pre-procedurally carefully planned and then pursued with mitral transcatheter edge-to-edge repair followed by prophylactic Impella-assisted PCI. Under haemodynamic support, retrograde CTO PCI via a patent saphenous vein graft was performed with drug-eluting stent implantation and intravascular ultrasound-confirmed optimisation, achieving TIMI 3 flow. The patient remained haemodynamically stable, with an uneventful post-procedural course and no vascular or cardiac complications. This case illustrates how a staged Impella-protected PCI strategy can facilitate revascularisation in post-CABG patients with advanced LV dysfunction and be integrated into a timely planned and patient-tailored approach accounting for ventricular function, valvular disease, and complex coronary anatomy when surgery is not feasible.
Ayoub et al. (Sat,) studied this question.