Mechanical circulatory support (MCS) is increasingly deployed in cardiogenic shock (CS) and advanced heart failure (HF) with the therapeutic aim of preserving end-organ perfusion while facilitating myocardial recovery and/or reverse remodeling. Recent randomized and observational studies have clarified patient selection and weaning strategies across temporary (tMCS) and durable (dMCS) platforms, yet center-to-center variability persists. This review synthesizes contemporary evidence while integrating prevailing opinion on defining recovery, prognostication, optimal timing and intensity of support, and practical algorithms for separation from MCS. Successful separation from MCS requires alignment of myocardial function, end-organ recovery, and hemodynamic reserve. We propose a practical, stepwise algorithm integrating clinical stability markers, vasoactive dosing (VIS), invasive hemodynamics (cardiac index, cardiac power output, filling pressures), and arterial pulsatility indices to structure de-escalation. A recovery-focused approach to MCS balances myocardial rest with early GDMT, vigilant complication surveillance, and hemodynamic-guided weaning. Prospective studies should validate standardized weaning protocols and incorporate omics-based phenotyping to personalize recovery pathways.
Kozaily et al. (Fri,) studied this question.