Cardiogenic shock (CS) and cardiac arrest (CA) are among the most lethal complications of acute cardiovascular disease, affected by high in-hospital mortality rates. Venoarterial extracorporeal life support (VA ECLS) is increasingly used either in adults or children with acutely impaired cardiac function refractory to conventional medical therapy. One of the most important concerns in VA ECLS is the increased left ventricular (LV) afterload due to retrograde aortic perfusion, depending on the configuration mode. This could slow myocardial recovery or further damage the myocardium and negatively affect survival. Currently, several different approaches have been proposed aiming at preventing or treating LV overload during VA ECLS.¹ However, the definition of LV overload and the practice of LV unloading are still poorly characterized and often based on local expertise with a great deal of variability.² We thus launched a nationwide survey among 18 tertiary cardio-surgery Italian centers to assess center-based LV overload identification and the actual use of LV unloading strategies.