Managing Cardiogenic Shock in the Era of Multimodal Mechanical Support: Bridging to Transplant or Recovery

To review the contemporary management of cardiogenic shock in the era of multimodal temporary mechanical circulatory support, with emphasis on phenotype-guided device selection, serial trajectory assessment, and bridging toward recovery, durable left ventricular assist device implantation, or heart transplantation.

Temporary mechanical circulatory support is now used to influence clinical outcomes, not just as rescue therapy. Devices like intra-aortic balloon pumps, microaxial flow pumps, and venoarterial extracorporeal membrane oxygenation affect heart function and recovery differently; their use should be tailored to the type of ventricular failure and monitored with hemodynamics and imaging. Expanded focus on upper-limb access and prolonged support has broadened temporary support's role in bridging patients to decision, recovery, or transplant. Cardiogenic shock remains a leading cause of mortality in acute myocardial infarction and advanced heart failure despite major advances in temporary mechanical circulatory support. Contemporary outcomes depend not only on device availability, but on matching support intensity to shock phenotype, recognizing trajectory early, minimizing complications, and preserving end-organ function. This review summarizes current evidence on device-specific physiology, escalation and weaning, pulmonary vascular considerations, and post-transplant outcomes, and proposes an integrated framework for individualized, trajectory-based decision-making.