Cardiogenic shock and complex high-risk percutaneous coronary interventions

Cardiogenic shock (CS) remains one of the most challenging clinical conditions in cardiovascular care, with persistently high mortality rates despite advances in reperfusion strategies and supportive therapies. This chapter provides a comprehensive overview of the definitions, classification, and phenotyping of CS, with a focus on evolving management strategies in acute myocardial infarction-related CS. We discuss the paradigm shift from a "time-to-balloon" to a "time-to-unload" approach, emphasizing the role of early mechanical circulatory support (MCS) to optimize hemodynamics and limit infarct size. Additionally, the chapter addresses the management of patients undergoing complex high-risk percutaneous coronary interventions (CHIP). It outlines the characteristics, indications, and limitations of available MCS devices-such as intra-aortic balloon pump (IABP), microaxial flow pump (mAFP), and veno-arterial extracorporeal membrane oxygenation (VA-ECMO)-with practical considerations for safe implantation and patient selection. Emphasis is placed on recent randomized trials and future directions in the management of both CS and CHIP patients.