The objective of this study is to assess the safety and efficacy of the Supira System in providing temporary cardiovascular hemodynamic support in patients undergoing HRPCI. Eligible patients will be randomized to undergo HRPCI with either the Supira System (investigational device) or the commercially available Impella systems (comparator device).

The Supira System is a minimally invasive percutaneous ventricular assist device (pVAD) that is intended to provide temporary hemodynamic support (≤ 4 hours) to patients undergoing HRPCI. The Supira Catheter is inserted percutaneously through the femoral artery, across the aortic valve, and into the left ventricle under fluoroscopic guidance, with the pump outlet remaining in the ascending aorta. The pump portion of the Catheter compresses during insertion in the Introducer Sheath and re-expands during use. It actively unloads the left ventricle by pumping blood from the ventricle into the ascending aorta and systemic circulation.

Inclusion Criteria:

• Hemodynamically stable and will undergo elective or urgent (not emergent) HRPCI, where hemodynamic support is deemed necessary, as determined by the institutional Heart Team
• Informed consent granted by the subject or legally authorized representative

Exclusion Criteria:

• Cardiogenic shock or acutely decompensated pre-existing chronic heart failure
• Stroke within 6 months of the index procedure, or any prior stroke with permanent neurologic deficit
• Left ventricular thrombus
• Aortic and iliofemoral anatomical conditions that preclude safe delivery and placement of the investigational device or the comparator device
• Ongoing renal replacement therapy with dialysis
• Presence of decompensated liver disease; severe liver dysfunction
• Infection of the proposed procedural access site or active infection
• Known hypersensitivity to intravenous contrast agents that cannot be adequately pre-medicated or known hypersensitivity to heparin, aspirin, adenosine diphosphate (ADP) receptor inhibitors, or nitinol
• Any condition, coagulopathy, planned procedure or contraindication that requires discontinuation of antiplatelet and/or anticoagulant therapy within 90 days of the index procedure
• Breastfeeding or pregnant or planning to become pregnant within 90 days of the HRPCI procedure
• Currently participating in active follow-up phase of another clinical study of an investigational drug or device or planning to enroll in such a study within 90 days of the HRPCI procedure
• Other medical, social, or psychological problems that, in the opinion of the Investigator, compromises the subject's ability to provide written informed consent and/or to comply with study procedures
• Considered to be part of a vulnerable population per the investigator's assessment