Nirat Beohar, MD, presents clinical data and a case illustrating high-risk PCI with mechanical circulatory support (MCS). He describes the characteristics of high-risk acute coronary syndrome (ACS) patients and reviews clinical evidence regarding the use of MCS, highlighting BCIS-1, the PROTECT II RCT and emerging data from the PROTECT IV RCT. He looks at what the guidelines say about MCS. He presents a high-risk PCI case performed in a step-wise approach: Impella®-supported reconstruction of the left main coronary artery and bifurcation, followed by PCI of the RCA and branches,\ and then TAVR. Dr. Beohar emphasizes the benefits of Impella support in this patient who required rotational atherectomy, intravascular lithotripsy and bifurcation PCI.