Use of Mechanical Left ventricuLar Unloading in Complex Higher-risk Indicated Procedures

Inclusion Criteria: * Age ≥18 years AND * Multidisciplinary heart team consensus for high risk PCI +/- MCS AND * Hemodynamically stable (SCAI A-B) AND * LVEF \<30% OR LVEF \<35% with moderate MR OR LVEF \<40% with severe MR AND * Complex left main disease (calcium modifying techniques deemed necessary OR 2-stent techniques, left dominant system) OR equivalent (ostial LAD and RCX) OR last remaining vessel (native). Exclusion Criteria: * Contraindications for Pulsecath IVAC2L: 1. severe aortic regurgitation 2. known presence of an LV thrombus (contrast echo/MRI) 3. Mechanical aorta valve prosthesis 4. severe aortic valve stenosis 5. peripheral arterial disease that would preclude placement of the PulseCath iVAC2L device * Cardiogenic shock defined as either SCAI CSWG stage C-E * Patient is intubated and mechanically ventilated * Stroke \<3 months * Major bleeding event \<3 months * History of bleeding diathesis or known coagulopathy (including heparin-induced thrombo-cytopenia), any recent GU or GI bleed, or will refuse blood transfusions.Renal replacement therapy * Pregnancy, or suspected thereof. * BMI \> 35 * Other medical, social, or psychological problems that, in the opinion of the Investigator, compromises the subject's ability to give written informed consent and/or to comply with study procedures. * Subject belongs to a vulnerable population (defined as individuals with mental disability, persons in nursing homes, impoverished persons, homeless persons, nomads, refugees and those permanently incapable of giving informed consent; vulnerable populations also may include members of a group with a hierarchical structure such as university students, subordinate hospital and laboratory personnel, employees of the Sponsor, members of the armed forces and persons kept in detention).