Cardiogenic shock, defined as decreased myocardial performance and cardiac output leading to end-organ hypoperfusion and hypoxemia, is associated with significant morbidity and mortality. Mechanical circulatory support such as veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is reserved for severe and refractory cases of cardiogenic shock. The use of VA-ECMO has increased significantly in the past decade with increasing indications including acute myocardial infarction, decompensated heart failure, post-cardiotomy syndrome (PCS), cardiac arrest, and refractory cardiopulmonary failure . While VA-ECMO provides full cardiopulmonary support and rapidly restores systemic perfusion, VA-ECMO is associated with adverse myocardial loading conditions by increasing afterload and worsening myocardial oxygen consumption, which leads to left ventricular distension, pulmonary edema/hemorrhage and impairs myocardial recovery . One of the strategies to unload the left ventricle is combined VA-ECMO and Impella (Abiomed, Danvers, MA) support, often referred to as “ECPELLA.” Left ventricular (LV) venting, also known as LV unloading, shifts the LV pressure-volume loop down and to the left. This reduces pressure-volume area and thus myocardial workload ( Fig. 1 A ) while also decreasing LV wall tension, as per Laplace's law ( Fig. 1 B). The net effect is a reduction in myocardial oxygen consumption while at the same time improving ventricular and pulmonary congestion.