Abstract
<jats:p>Left ventricular (LV) overload represents a central challenge in patients supported with veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Retrograde aortic flow increases LV afterload, predisposing patients to pulmonary edema, intracardiac thrombosis, and delayed myocardial recovery. This chapter reviews the pathophysiologic rationale, diagnostic criteria, and technical strategies for LV unloading during VA-ECMO, integrating physiologic insights with current clinical evidence. Unloading modalities, ranging from intra-aortic balloon pump and Impella™ (Abiomed, a Johnson & Johnson company) to trans-septal and surgical venting, differ in invasiveness, efficacy, and risk profile. While physiologic benefits are well-established, robust randomized data demonstrating survival improvement remain lacking. Observational studies and meta-analyses suggest potential reductions in pulmonary congestion and enhanced ECMO weaning with unloading, but these findings are confounded by patient selection and institutional expertise. A physiology-guided approach, based on dynamic assessment of pulsatility, aortic valve motion, and filling pressures, may optimize outcomes while minimizing device-related complications. Future research should focus on standardized definitions of LV distension, early versus selective unloading strategies, and next-generation hybrid systems integrating active decompression and oxygenation. Ultimately, the goal is not routine device implantation but restoration of hemodynamic balance between ECMO support and myocardial workload.</jats:p>