OBJECTIVES: The newly introduced percutaneous Ventricular Assist Devices (pVAD) have been shown to provide better hemodynamic support but there is no evidence that they improve clinical outcomes in high-risk percutaneous coronary intervention (PCI) compared with the intra-aortic balloon pump (IABP), the current standard of care. We aim to evaluate the cost-effectiveness of pVAD compared with IABP in patients undergoing high-risk PCI in Ontario. METHODS: A cost-utility analysis was conducted from the Ontario public payer perspective using a 10-year time horizon. A Markov cohort model was developed to simulate the process of patients going through PCI treatment. Patients in the post-PCI state (no complication) may either stay in this health state or transition to death or develop Major Adverse Cardiac Events (MACE), specifically “acute myocardial infarction”, “stroke” and “repeat revascularization”. Transition probabilities and mortality rates were calculated using data from the PROTECT II study, a randomized controlled trial comparing pVAD and IABP. Costs were reported in 2016 Canadian dollars and obtained from the Ontario Case Costing Initiative, the CCN Cardiac Registry and the published literature. Utilities were obtained from various Quality of Life studies. Probabilistic sensitivity analyses were used to assess parameter uncertainties. RESULTS: High-risk PCI supported by pVAD resulted in a loss of 0.109 QALYs with an additional cost of $24,260 per patient, compared to IABP. As such, pVAD was dominated (more costly and less effective). Even in scenarios that favoured pVAD (such as setting the long-term MACE probabilities between treatments to be the same at 90 days and using the same mortality rate for both arms), it was still not cost-effective compared with IABP. CONCLUSIONS: Our economic evaluation showed that the pVAD was not an economically attractive alternative to IABP in high-risk PCI patients in Ontario. Further research will be needed to identify a population in which pVAD is clinically and economically attractive.