Background. If surgical revascularization is not feasible, high-risk PCI is a viable option for patients with complex coronary artery disease. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides hemodynamic support in patients with a high risk for periprocedural cardiogenic shock. Objective. is study aims to provide data about short-term outcomes of elective highrisk PCI with ECMO support. Methods. A retrospective single-center registry was performed on patients with high-risk PCI receiving VA-ECMO support. e short-term outcome was defined as the incidence of major adverse cardiac events (MACE) during the hospital stay and within 60 days after discharge. Results. Between January 2020 and December 2021, 14 patients underwent high-risk PCI with ECMO support. e mean age was 66.5 (±2.5) and the majority was male (71.4%) with a mean left ventricular ejection fraction of 33% (±3.0). Complexity indexes were high (STS-PROM risk score: 2.9 (IQR 1.5-5.8), SYNTAX score I: 35.5 (±2.0), SYNTAX score II (PCI): 49.8 (±3.2)). Femoral artery ECMO cannulation was performed in 13 patients (92.9%) requiring additional antegrade femoral artery cannula in one patient because of periprocedural limb ischemia. e mean duration of the ECMO run was 151 (±32) minutes. One patient required prolonged ECMO support and was weaned after 2 days. Successful revascularization was achieved in 13 patients (92.8%). Procedural success was achieved in 12 patients (85.7%) due to one unsuccessful revascularization and one procedural death. MACE during hospital stay occurred in 4 patients (28.6%) and within 60 days after discharge in 2 patients (16.7%). Conclusion. High-risk PCI with hemodynamic support using VA-ECMO is a feasible treatment option, if surgical revascularization is considered very high risk. Larger and prospective studies are awaited to confirm the benefits of ECMO support in elective high-risk PCI comparing ECMO with other mechanical circulatory support devices, including coaxial left cardiac support devices and IABP. Trial Registration. is trial is registered with NCT05387902.

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Shockwave lithotripsy is a novel therapy to treat severely calcified lesions. The effectiveness of shockwave lithotripsy to treat severely calcified lesions and stent underexpansion due to severe calcifications has been demonstrated. However, this is the first case to demonstrate the use of shockwave lithotripsy in stent underexpansion due to severely calcified in-stent restenosis. A woman in her early 50s presented with angina. The coronary angiogram showed severe three-vessel coronary artery disease with in-stent restenosis in the left anterior descending. After stent implantation in the left anterior descending, there was persisting stent underexpansion due to severely calcified in-stent restenosis. Shockwave lithotripsy contributed to the improvement of angiographic and haemodynamic results. Although evidence is still limited, shockwave lithotripsy could be a valuable tool for treatment of stent underexpansion as a result of severely calcified in-stent restenosis. More studies are needed to confirm the incremental value of shockwave lithotripsy in stent underexpansion.

Background Despite optimal angiographic result of Percutaneous Coronary Intervention (PCI), residual disease at the site of the culprit lesion can lead to Major Adverse Cardiac Events (MACE) at follow-up [1]. Post-PCI physiological assessment can identify residual stenosis. Purpose The aim of this meta-analysis is to investigate data of studies with minimum follow-up of 6 months examining post-PCI physiological assessment in relation with long-term outcomes. Methods Studies were included in the meta-analysis after performing systematic search of the literature on 10th of January 2022. The primary endpoint was the incidence of MACE, Vessel-Orientated Cardiac Events (VOCE) or Target Vessel Failure (TVF). Secondary endpoints included the incidence of death, myocardial infarction (MI) and Target Vessel Revascularization (TVR). Results Low post-PCI FFR, reported in seven studies [2–8], including 4017 patients, was associated with an increased rate of the primary endpoint (HR 2.06; 95%-CI 1.37–3.08). One study reported about impaired post-PCI (instantaneous wave-free ratio) iFR in relation with MACE, showing a significant association (HR 3.38; 95%-CI 0.99–11.6) [9]. Low post-PCI QFR, reported in three studies [10–12], including 1181 patients, was associated with increased rate of VOCE (HR 3.02; 95%-CI 2.13–4.30). Combining data of all modalities, impaired physiological assessment showed an increased rate of the primary endpoint (HR 2.32; 95%-CI 1.71–3.16) and secondary endpoints including death (HR 1.35; 95%-CI 1.01–1.82), MI (HR 2.50; 95%-CI 1.36–4.58) and TVR (HR 2.88; 95%-CI 1.91–4.35). Conclusions Impaired post-PCI physiological assessment is associated with an increase in adverse cardiac events and individual endpoints including death, MI and TVR. Prospective studies are awaited whether physiology-based optimization of PCI results in better clinical outcome. Funding Acknowledgement Type of funding sources: None.