In patients in cardiogenic shock (CS), mechanical circulatory support (MCS) may improve systemic perfusion without increasing myocardial work. Restoration of oxygen delivery with reduced myocardial oxygen demand favors myocardial recovery. The hemodynamic effects of MCS have been extensively studied and elegantly reviewed previously. Pressure-volume loop simulations suggest that although venoarterial extracorporeal membrane oxygenation (VA-ECMO) may improve systemic perfusion, accompanying consequences on left ventricular (LV) dynamics may be detrimental.1 In severe LV dysfunction, this has significant implications, potentially resulting in LV distension and pulmonary congestion.2 Myocardial recovery may be limited, negatively affecting long-term prognosis.2 A recent series reported 22% subclinical LV distension (LVD) and 7% overt LVD requiring immediate decompression. Myocardial recovery was found to be inversely related to the degree of LVD.3 Increased pulmonary congestion after VA-ECMO initiation is similarly associated with poorer prognosis.4 Other MCS devices may have superior LV unloading properties, but do not offer comparable cardiopulmonary support. The purpose of this article is to review strategies to prevent, recognize, and treat LVD, a key to maximizing the benefits of VA-ECMO.