Cardiac-limited ventilator liberation in cardiogenic shock and advanced heart failure: a critical care cardiology framework

Respiratory support is common in cardiogenic shock and advanced heart failure, yet disease-specific evidence guiding intubation, spontaneous breathing trials, extubation, post-extubation support, and liberation during mechanical circulatory support remains limited. This narrative review synthesizes physiology, randomized evidence from adjacent populations, cardiogenic shock registries, weaning-induced pulmonary edema studies, and mechanical circulatory support/VA-ECMO literature. We distinguish weaning-induced pulmonary edema as a diagnostic phenotype from cardiac-limited ventilator liberation as a broader decisional framework in which pulmonary mechanics appear adequate but cardiovascular reserve, respiratory effort, or device strategy limits liberation. Because existing evidence is largely observational, this review does not provide guideline-level recommendations. Instead, it organizes bedside assessment, identifies where evidence ends and expert opinion begins, and proposes research priorities for critical care cardiology.