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Early management strategies were dominated by the intra-aortic balloon pump (IABP), widely adopted on physiological grounds despite limited randomized evidence and later declining use due to downgraded guideline recommendations. Subsequent shifts toward more potent tMCS devices, including transaortic micro-axial flow pumps and venoarterial extracorporeal membrane oxygenation (VA ECMO), were driven by the pursuit of improving systemic perfusion and ventricular unloading. However, enhanced hemodynamic support has not consistently translated into superior clinical outcomes and is frequently accompanied by substantial device-related complications. Increasing recognition of the complex and patient-specific physiology of cardiogenic shock has fueled a transition from device-centred to patient-centred strategies, emphasizing tailored support configurations, multimodal monitoring, and physiology-driven decision-making. Adjunct left ventricular unloading during VA ECMO has emerged as a promising yet controversial approach, with ongoing trials expected to clarify its clinical role. Recent evidence, including the DanGer Shock trial, suggests that timely initiation of appropriately selected tMCS may improve longer-term outcomes in selected populations. Parallel advances in biomedical engineering have enabled physiology-based cardiovascular simulators that allow systematic comparison of tMCS strategies, pharmacological support, and device hemocompatibility under controlled conditions. When extended to virtual populations, these in silico approaches can complement clinical evidence through virtual clinical trials, potentially reducing the size and cost of traditional studies. Together, these developments highlight a new era of patient-centred critical care and biomedical innovation in cardiogenic shock.<\/jats:p>","DOI":"10.1177\/02676591261424661","type":"journal-article","created":{"date-parts":[[2026,5,6]],"date-time":"2026-05-06T06:30:36Z","timestamp":1778049036000},"update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":0,"title":["Spoilt for choice? 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