Post-cardiotomy cardiogenic shock (PCCS) remains one of the most lethal complications of cardiac surgery, with high in-hospital mortality despite major improvements in operative techniques, and intensive care management. Temporary mechanical circulatory support (tMCS) is widely applied as a rescue therapy for refractory PCCS. However, outcomes remain suboptimal, also due to delayed initiation after the onset of severe hemodynamic collapse and irreversible compromised end-organ states. This review summarizes current concepts of PCCS management and evaluates the emerging role of prophylactic tMCS within the framework of “protected cardiac surgery”.

A narrative review of the current international guidelines, expert consensus statements, and major observational studies addressing post-cardiotomy tMCS and prophylactic support strategies was carried out. Emphasis was placed on pathophysiology, indications, timing of support, and device selection.

Prophylactic tMCS has been applied in selected high-risk scenarios including acute coronary syndromes, acute valvular dysfunction, ventricular septal rupture, papillary muscle rupture, advanced heart failure requiring bridge-to-decision or to-transplant, or difficult and complex weaning from cardiopulmonary bypass. The concepts of preoperative (Type 1), planned intraoperative (Type 2), and unplanned early intraoperative (Type 3) protected cardiac surgery provide a practical framework for a timely evaluation and related action aiming at metabolic stabilization to reduce or prevent postoperative low cardiac output syndrome. Successful implementation depends on multidisciplinary Heart Team decision-making, advanced hemodynamic assessment, and tailored perfusion strategies as well as device selection also based on local resources and expertise.

Prophylactic tMCS represents a paradigm shift from reactive rescue therapy toward proactive cardio-circulatory protection in selected high-risk patients undergoing cardiac surgery procedures. While early observational data are encouraging, prospective trials, standardized risk stratification tools, and cost-effectiveness analyses are required to define its role in modern cardiac surgery.