The step forward for VA ECMO: left ventricular unloading!

VA ECMO is nowadays widely recognized as part of the armamentarium for fighting refractory acute heart failure. However, this system pays immediate gratification with high flows provided and rapid whole-body reperfusion but there is often a price to be paid a day later when the lungs become white. This phenomenon is secondary to the flow changes from the femoral artery which significantly affects the pressure-volume (PV) loop of the left ventricle. Therefore, although the use of VA ECMO is an exciting tool to resuscitate patients dying from acute heart failure, overall survival in this scenario remains poor especially if we target for myocardial recovery of the native heart (1).