Planned Versus Standby V-A ECMO Strategy During High-Risk PCI: A Retrospective Cohort Study.

BACKGROUND: The role of mechanical circulatory support (MCS) in high-risk percutaneous coronary intervention (HR-PCI) remains controversial, and the optimal timing of its initiation is not well defined. Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) provides full hemodynamic support; however, comparative data on planned versus standby strategies are limited. AIM: To compare clinical outcomes of planned versus standby V-A ECMO support in patients undergoing elective HR-PCI, with a focus on the impact of timing of ECMO initiation. METHODS: This single-center retrospective observational study included 74 consecutive patients who underwent high-risk PCI between 2019 and 2025 and were managed according to a preprocedurally determined V-A ECMO strategy. Before PCI, the multidisciplinary Heart Team selected either a planned strategy (n = 43), in which V-A ECMO was initiated before PCI, or a standby strategy (n = 31), in which ECMO equipment and vascular access were prepared in advance, but ECMO was initiated only in response to predefined intraprocedural hemodynamic deterioration. The primary endpoint was in-hospital major adverse cardiac and cerebrovascular events (MACCE), defined as a composite of death, myocardial infarction, stroke, and repeat revascularization. RESULTS: No statistically significant differences were observed in the measured baseline variables. ECMO support during PCI was required in 19/32 (61.3%) of patients in the standby-strategy group. The incidence of in-hospital MACCE was significantly higher in the standby-strategy group compared with the planned-strategy group (48.4% vs. 14.0%, p = 0.002). The standby-strategy group also had longer ICU stay (8 [5-12] vs. 6 [4-9] days, p = 0.03) and hospital stay (15 [11-20] vs. 12 [9-16] days, p = 0.02), as well as higher vasoactive-inotropic scores (p = 0.033). In multivariable analysis, the standby strategy was associated with higher odds of in-hospital MACCE after adjustment (adjusted OR, 4.20; 95% CI, 1.35-13.10; p = 0.013). CONCLUSIONS: In this single-center retrospective cohort of patients undergoing elective HR-PCI, a planned V-A ECMO strategy was associated with a lower incidence of in-hospital MACCE than a standby strategy. Given the nonrandomized treatment allocation, inclusion of standby patients who did not ultimately require ECMO, and limited number of events, these findings are hypothesis-generating and do not establish a causal benefit of planned ECMO or harm from rescue initiation.