Objectives. To compare two different forms of mechanical circulatory support (MCS) in patients with complex high-risk indicated PCI (CHIP): the Impella CP system and veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Background. To prevent hemodynamic instability in CHIP, various MCS systems are available. However, comparable data on different forms of MCS are not at hand. Methods. In this multicenter observational study, we retrospectively evaluated all CHIP procedures with the support of an Impella CP or VA-ECMO, who were declined surgery by the heart team. Major adverse cardiac events (MACE), mortality at discharge, and 30-day mortality were evaluated. Results. A total of 41 patients were included, of which 27 patients were supported with Impella CP and 14 patients with VA-ECMO. Baseline characteristics were well-balanced in both groups. No significant difference in periprocedural hemodynamic instability was observed between both groups (3.7% vs. 14.3%; p = 0.22 ). The composite outcome of MACE showed no significant difference (30.7% vs. 21.4%; p = 0.59 ). Bleeding complications were higher in the Impella CP group, but showed no significant difference (22.2% vs. 7.1%; p = 0.22 ) and occurred more at the non-Impella access site. In-hospital mortality was 7.4% in the Impella CP group versus 14.3% in the VA-ECMO group and showed no significant difference ( p = 0.48 ). 30-Day mortality showed no significant difference (7.4% vs. 21.4%; p = 0.09 ). Conclusions. In patients with CHIP, there were no significant differences in hemodynamic instability and overall MACE between VA-ECMO or Impella CP device as mechanical circulatory support. Based on this study, the choice of either VA-ECMO or Impella CP does not alter the outcome.

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Introduction:The minimalistic hybrid approach (MHA) is an algorithm to perform chronic total occlusion (CTO) percutaneous coronary intervention (PCI). The current study aims to evaluate the distribution of patients among the five different treatment strategies, the different techniques used in each strategy, the overall procedural success, and the safety of the MHA algorithm.Methods: Data from a consecutive series of patients with a CTO who underwent elective PCI between February 2019 and July 2021 were prospectively collected and retrospectively analyzed.Results: One hundred and forty-three CTOPCI in 135 patients were approached according to the MHA algorithm: 134 CTO (93.7%) were successfully recanalized and 9 procedures failed. About half of the procedures (48.3%) were approached using strategy A: antegrade "blind wiring" with contralateral retrograde options, making this the most popular strategy. A total of 89 procedures (62.2%) were completed with a single guiding catheter; in 86 (96.6%) a forearm approach was used. The remaining 54 cases were performed with dual access; in the majority of these patients (90.7%), a bilateral forearm approach was used. The only reason to use the femoral access was inadequate forearm access. One hundred and fiftyfour out of 197 (78.2%) access sites were 6 French sheaths. Conclusion:MHA is a stepwise approach focused on the forearm approach to reduce the number of access sites and catheter size used in CTOPCI while maintaining proficiency and safety. Operators should be warned that this approach should be adopted only by experienced CTO operators who master all the strategies of the classic hybrid algorithm and the forearm approach.

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