Transcatheter management of cardiogenic shock in severe aortic stenosis

Management of cardiogenic shock (CS) in the setting of severe aortic stenosis (AS) remains clinically challenging, owing to the coexistence of fixed valvular obstruction, limited myocardial reserve, and rapidly evolving end-organ hypoperfusion. In this context, early identification of patients unlikely to recover with medical therapy alone and timely transition to definitive valve intervention are critical determinants of outcome. Despite growing clinical experience, decision-making in this setting remains heterogeneous and largely informed by observational evidence. Herein, in the present review, we synthesize contemporary evidence on transcatheter strategies for AS-related CS, with emphasis on clinical decision-making during the acute phase. A physiology-driven approach to early assessment and hemodynamic stabilization is outlined, integrating echocardiography, invasive monitoring, and tailored pharmacologic support to inform escalation pathways. Mechanical circulatory support (MCS) is discussed as a selective, time-limited strategy to achieve stabilization and facilitate procedural planning, while accounting for the unique physiological limitations imposed by fixed valvular obstruction. Available data on balloon aortic valvuloplasty and urgent or emergent transcatheter aortic valve implantation (TAVI) are examined with respect to procedural feasibility, early outcomes, and their positioning within bridging or definitive treatment pathways in CS. Collectively, this work proposes a pathway-oriented framework for AS-related CS that prioritizes early recognition, coordinated multidisciplinary decision-making, and timely progression to definitive valve intervention, tailored to patient risk profile and institutional expertise.