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BackgroundPost-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".MethodsA 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.ResultsProphylactic 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.ConclusionsProphylactic 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.