Planned Versus Standby V‐A ECMO Strategy During High‐Risk PCI: A Retrospective Cohort Study
Mykhailo Todurov, Borys Todurov, Yulia Zybaha, Artem Kipot, Stepan MaruniakABSTRACT
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.