Impella-assisted intracoronary lithotripsy of heavily calcified left main lesion in a patient with severely impaired ejection fraction and the last remaining patent vessel.

A 56-year-old man with the last remaining patent vessel, heavily calcified significant left main (LM) stenosis (Fig. 1A) and chronic total occlu - sion of both right coronary artery and circumflex branch was referred to our institution for revas - cularization of the LM lesion. Patient was turned down from surgery due to severely impaired left ventricular ejection fraction (LVEF) of 12% and multiple comorbidities. Due to high surgical risk (EuroScore II of 23.05%), the decision to proceed with Impella-assisted revascularization was made. Calcified LM lesion was predilated with multiple non-compliant balloons (NCBs) (up to 4.0 mm) (Fig. 1B), however the full balloon expansion was