While great strides have been made in the management of heart failure syndromes, acute refractory cardiogenic shock carries a dismal prognosis. Initial treatment with inotropes and balloon counterpulsation can restore hemodynamics, but many patients deteriorate and succumb to multisystem organ failure if timely mechanical circulatory support is not established. Institution of support is intended as a life-saving measure where the final treatment strategy remains uncertain. This scenario is referred to as "bridge to decision." Notably, most of these patients present to community hospitals, where advanced mechanical support technologies are scarce or nonexistent. Delays in referral to a tertiary center contribute to the bleak outcomes. Herein, we review the initial management of acute heart failure and refractory cardiogenic shock, profile the typical patient, delineate current options for mechanical support in patients with acute refractory cardiogenic shock, and propose suggestions for the establishment of a seamless transfer process of these ill patients to tertiary centers.