Sky is the limit for Impella-assisted percutaneous coronary intervention: Four technologies, three vessels, two bifurcations and one chronic total occlusion

A 73-year-old woman after percutaneous coronary intervention (PCI) of the left main (LM), left anterior descending (LAD) artery and diagonal branch with implantation of 5 drug-eluting stents (2020) was admitted due to heart failure exacerbation. Echocardiography showed left ventricular ejection fraction (LVEF) of 13%, severe secondary mitral regurgitation (MR) and moderate tricuspid regurgitation (TR). Coronary angiography demonstrated multivessel disease (SYNTAX score 47.5; Fig. 1A, B) with in-stent restenosis of the LM and LAD and chronic total occlusion of the circum - flex (Cx). Considering the high risk of mortality (EuroSCORE II 22.1