The cardiovascular intensive care unit (CVICU) presents unique opportunities and challenges for integrating palliative care. A growing population of patients living longer with advanced cardiac disease, persistent symptoms, and functional limitations may benefit from early palliative involvement. With increasing use of advanced therapies such as mechanical circulatory support, many patients die in the CVICU, while survivors often experience long-term physical and psychosocial burdens. Despite evidence that early palliative care improves quality of life and reduces nonbeneficial interventions, it remains underutilized because of prognostic uncertainty and inconsistent referral guidance. This review explores therapies, palliative roles, and end-of-life practices in the CVICU.

Failure to rescue (FTR), defined as mortality after a postoperative complication, is now a central quality metric in cardiac surgery, where high-acuity patients and resource-intensive care increase vulnerability to deterioration. Although complications are common, survival depends on timely recognition, effective escalation, and coordinated multidisciplinary management. This article synthesizes current evidence on the epidemiology, mechanisms, and system-level drivers of FTR, highlighting how patient, provider, and institutional factors influence rescue success. We outline practical, evidence-based strategies to reduce FTR in cardiac surgery after prolonged ventilation, renal failure, stroke, and reoperation, by emphasizing protocolized care, staffing models, team communication, and rapid response infrastructure.

Enhanced recovery after cardiac surgery (ERAS) advocates for consistent and standardized delivery of evidenced-based perioperative care. Multidisciplinary teams deliver integrated patient care elements across all phases of care. Elements include risk-screening, prehabilitation, nutritional support, organ protection, patient blood management, early mobilization, optimal analgesia, and prevention of complications. Implementation of an ERAS program has been shown to improve patient recovery and reduce complications, length of stay, and resource utilization. However, the evidence is inconsistent and often low grade. Ongoing research, education, and institutional commitment remain essential for continued quantification of ERAS and its role in caring for cardiac surgical patients.

Heart transplantation is the definitive treatment for end-stage heart failure. Post-transplant care is dynamic and complex, requiring a thoughtful multidisciplinary approach. Invasive hemodynamic monitoring is central to guiding inotrope and vasopressor titration to optimize allograft function and end-organ perfusion. Vigilant assessment for primary graft dysfunction is essential and informs escalation to mechanical circulatory support when needed. As hemodynamics and graft function stabilize, patients are liberated from mechanical ventilation, volume status is optimized, nutrition and mobility are prioritized, and pharmacologic and mechanical supports are weaned. Concurrently, immunosuppression is titrated and patients are monitored closely for infection.

Durable left ventricular assist devices (LVADs) have transformed the management of advanced heart failure, but early post-operative management remains a time of heightened vulnerability with disproportionate impact on short-term and long-term outcomes. This article provides a practical, physiology-driven framework for intensive care unit (ICU) management following LVAD implantation, emphasizing early hemostasis and anticoagulation strategies, systematic hemodynamic assessment, and optimization of right ventricular function. Additional sections address respiratory management, dysrhythmia control, nutrition, and early mobilization as essential components of recovery. By synthesizing contemporary evidence with bedside decision-making, this guide aims to support multidisciplinary ICU teams in standardizing care.

Point-of-care ultrasound (POCUS) is an essential tool in perioperative and cardiac critical care, providing rapid, bedside evaluation of cardiac function, pulmonary pathology, and volume status. This article introduces a protocolized, whole-body POCUS approach centered on the sonographic congestion cascade, conceptualizing the cardiopulmonary venous system as a continuous physiologic unit. By integrating cardiac, lung, and multisite venous Doppler findings, clinicians can identify shock etiologies, characterize congestion phenotypes, and guide individualized, physiology-driven management in patients with undifferentiated shock and respiratory failure.

Postcardiotomy shock (PCS) is a complex, high-mortality complication following cardiac surgery, driven by cardiopulmonary bypass-related inflammation, vasoplegia, myocardial dysfunction, and pulmonary hypertension. Conventional shock definitions are poorly applicable to this population; a vasoactive inotropic score greater than 20 to 25 with evidence of hypoperfusion is proposed as a practical operational definition. Overlapping PCS phenotypes (cardiogenic, vasoplegic, obstructive, arrhythmic, mixed) necessitate multimodal hemodynamic profiling incorporating pulmonary artery catheter data, echocardiography, and dynamic perfusion indices. Management focuses on judicious fluid and blood product administration, phenotype-directed inotropes and vasopressors, lung-protective ventilation, and early initiation of temporary mechanical circulatory support.

Patients admitted to contemporary cardiac intensive care units (ICUs) increasingly present with complex low-flow states and multisystem organ dysfunction, particularly in the perioperative cardiac surgery setting. This article outlines a systematic, organ-based approach to optimizing extracardiac organ function in patients with shock, emphasizing respiratory, renal, vascular, neurologic, hematologic, gastrointestinal, and endocrine management. Key principles include understanding cardiopulmonary interactions, minimizing secondary organ injury, tailoring supportive therapies to physiologic profiles, and applying ICU best practices. Coordinated, multidisciplinary optimization of noncardiac organ systems is essential to improve surgical candidacy, reduce complications, and enhance outcomes in this high-risk population.

Surgical or endovascular repair is the cornerstone of interventional management for acute ascending aortic dissection and complicated descending aortic dissection. However, perioperative medical therapy plays a decisive role in stabilizing patients, preventing propagation of dissection and mitigating end-organ injury. Perioperative clinicians must navigate competing priorities: reducing aortic shear stress while maintaining adequate perfusion, managing severe pain and sympathetic activation, addressing malperfusion syndromes, and preparing patients for urgent or emergent intervention. This article outlines a practical framework for perioperative medical management across the continuum of care.

Valvular heart disease is an uncommon but high-risk cause of cardiogenic shock requiring rapid, multidisciplinary management aimed at bridging patients to definitive surgical or transcatheter valve intervention. Early comprehensive Doppler echocardiography is essential, as clinical signs may be subtle. Distinguishing decompensated chronic valvular disease from acute unstable lesions guides urgency and treatment strategy. Medical stabilization and mechanical circulatory support vary markedly between stenotic and regurgitant lesions, and standard shock therapies may be harmful in specific contexts. Transcatheter approaches are preferred when feasible, though their expanding use introduces added complexity in cardiac intensive care.

Right ventricular (RV) failure is a clinically distinct entity with significant prognostic implications across multiple cardiovascular conditions. Its diagnosis is challenging due to overlapping features with left ventricular failure, often leading to delayed recognition. This article reviews the unique pathophysiology, clinical presentation, and diagnostic strategies for RV failure, emphasizing hemodynamic assessment. A structured approach to medical management is presented, focusing on optimization of preload, afterload, contractility, and rhythm control. Disease-specific considerations and timely escalation to mechanical circulatory support are discussed to improve outcomes in patients with RV-related cardiogenic shock.

Management of venoarterial-extracorporeal membrane oxygenation for cardiogenic shock requires prompt diagnosis, rapid intervention with individualized cannulation, adherence to clear device and anticoagulation management protocols, and close hemodynamic and end-organ monitoring. Assessment of left ventricular unloading and oxygen delivery is essential to prevent complications such as malperfusion of end organs, limb ischemia, pulmonary edema, and Harlequin (North-South) syndrome. Daily evaluation guides weaning for myocardial recovery and transition to durable support, transplant, or palliative care. Multidisciplinary coordination with critical care clinicians, early involvement of advanced heart failure and transplant teams, and clear communication with families are crucial to align therapy with patient.

Cardiogenic Shock remains one of the deadliest clinical conditions in the world. Despite technological advances, mortality rates remain unacceptably high. While recently published data in acute myocardial infarction-cardiogenic shock (AMI-CS) suggest improved outcomes with protocolized use of early temporary mechanical circulatory support (tMCS) real-world observational and registry data in both AMI-CS and heart failure-related CS suggest opportunities to improve survival through use of shock teams, early escalation to tMCS and use of hemodynamic and hemometabolic monitoring. Here we review current literature on escalation of care in cardiogenic shock and provide recommendations for optimal escalation through organized systems of care.

In the cardiovascular intensive care unit (CVICU), hemodynamic monitoring provides the foundation for evaluating tissue perfusion, guiding fluid resuscitation, titrating vasoactive medications, and assessing response to therapy. However, the optimal approach to hemodynamic monitoring remains a subject of ongoing debate. This article highlights the nuances of hemodynamic monitoring in the CVICU and reviews both established and emerging technologies and how they may be combined with clinical judgement to optimize patient outcomes for the critically ill patients.