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One consequence of placing a patient with cardiogenic shock on veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is the impairment of left ventricular (LV) unloading. This is hypothesized to be a result of increased LV afterload 2/2 increased retrograde aortic flow, particularly in patients with
already suboptimal cardiac contractility.

Concomitant Impella placement with VA-ECMO to facilitate unloading as well as staged de-escalation of mechanical support has been shown to reduce hospital mortality in certain cases albeit at the cost of severe hemolysis of having two MCS devices (CardShock Trial, 2015). In patients with profound LV failure, how do you go about thinking of the timing and/or threshold for mechanical (or ionotropic) LV unloading? Do all VA-ECMO patients require LV unloading or only a subset?