This overview article provides a framework for this series of articles. It addresses European recommendations and best practices for patient management and mechanical circulatory support (MCS) during high risk intervention, highlighting the following topics:

• Patient selection 
• Pre-procedural workup
• Anticoagulation
• Revascularization
• Handling patients in the cath lab
• Bailout and complication management

The authors—Prof. Nikos Werner, Dr. Francesco Burzotta, and Prof. Jan-Malte Sinning—explain that a deep dive into literature, data, and personal expert opinion reveals differing opinions on the use of MCS for Protected PCI. While some operators believe that the hemodynamic support provided by MCS helps them achieve complete revascularization and renal protection, others describe increased bleeding and vascular complication rates and a lack of hard outcome data for the use of MCS. The authors look forward to the results from the ongoing PROTECT IV randomized, controlled trial (RCT) to help answer questions for all these operators.

As they await RCT data, the authors emphasize the important impact that standardized approaches for patient selection, Impella pump insertion, monitoring, and postprocedural management can have on complication rates and outcomes in patients managed with the Impella system. They note that various centers worldwide have developed best practices that have contributed to lower complication rates as seen in the PROTECT III registry. The aim of this series of articles is to share strategies from experienced centers in Europe to help operators assess each situation and employ optimal treatment strategies.