We have read with great interest a manuscript written by Monteagudo-Vela and colleagues showing immediate improvement in hemodynamics, markers of end-organ perfusion, and clinical outcomes with the use of percutaneous trans-catheter micro-axial left ventricular assist device Impella (Abiomed, Danvers, MA) insertion in patients with various phenotypes of cardiogenic shock. Though prospective data is evolving previous large-scale studies have not demonstrated a clear benefit of Impella use over intra-aortic balloon pumping in several heterogeneous clinical settings. It is clear that understanding the optimal clinical scenario where Impella use leads to an improvement in hard clinical endpoints is yet to be achieved.