Topics: From underflow to leaving suckers on during protamine—risk, mechanism, and management. IABP and Impella—patient selection, timing, and weaning strategy.

Learning objectives: Recognize perfusion errors around protamine reversal and how to prevent them. Apply a stepwise strategy when flows are low or suckers remain on. Compare IABP and Impella indications, contraindications, and outcomes. Build practical checklists for OR communication and handoff.