Impella™-protected PCI in a post-CABG patient with advanced biventricular dysfunction and mitral regurgitation

Patients with advanced coronary artery disease (CAD), severely reduced left ventricular (LV) ejection fraction, and prior coronary artery bypass grafting (CABG) present with complex revascularization challenges requiring individualized, multidisciplinary decision-making and pre-procedural strategy planning. Protected percutaneous coronary intervention (PCI) using percutaneous temporary mechanical circulatory support, such as the Impella™ microaxial flow pump, may enable complex revascularization in carefully selected patients at high risk of peri-procedural haemodynamic compromise. We describe a male patient with advanced ischaemic cardiomyopathy, severe functional mitral regurgitation, and complex multivessel CAD, including chronic total occlusion (CTO) of the left anterior descending artery, following prior CABG. After Heart Team discussion and in the context of prohibitive surgical risk, a staged strategy was carefully planned pre-procedurally and then pursued with mitral transcatheter edge-to-edge repair, followed by prophylactic Impella-assisted PCI. Under haemodynamic support, retrograde CTO PCI via a patent saphenous vein graft was performed with drug-eluting stent implantation and intravascular ultrasound-confirmed optimization, achieving TIMI 3 flow. The patient remained haemodynamically stable, with an uneventful post-procedural course and no vascular or cardiac complications. This case illustrates how a staged Impella-protected PCI strategy can facilitate revascularization in post-CABG patients with advanced LV dysfunction and be integrated into a timely, planned, and patient-tailored approach accounting for ventricular function, valvular disease, and complex coronary anatomy when surgery is not feasible.