Cardiogenic shock (CS) in patients with structural heart disease (SHD) and severe valvular abnormalities poses unique challenges to traditional mechanical circulatory support (MCS) strategies, such as intra-aortic balloon pumps and ventricular assist devices. These devices may fail to address the complex interplay between ventricular unloading and systemic perfusion. Left atrial venoarterial extracorporeal membrane oxygenation (LAVA-ECMO) incorporating left atrial (LA) drainage into the ECMO circuit to reduce left ventricular (LV) preload, mitigate pulmonary congestion, and maintain systemic perfusion. This review explores the pathophysiologic principles and clinical applications associated with LAVA-ECMO. Studies have demonstrated its efficacy in managing CS due to severe valvular disease, biventricular failure, and complex hemodynamic profiles, such as those complicated by aortic regurgitation or ventricular septal defect. Although traditional venoarterial ECMO can incorporate LA drainage, LAVA-ECMO offers distinct advantages by actively unloading the left ventricle, thereby preventing such complications as LV distension and pulmonary edema. Clinical evidence suggests its role as a bridge to definitive interventions, including transcatheter and surgical valve replacements. Despite these benefits, challenges remain, including high in-hospital mortality and complications such as bleeding. LAVA-ECMO represents a transformative advancement in MCS, offering superior hemodynamic stabilization and myocardial recovery for patients with refractory CS and severe valvular disease. Its ability to address LV unloading directly positions it as a pivotal tool in critical care and SHD management; however, significant gaps in evidence, particularly in long-term outcomes and optimal patient selection, underscore the need for further research.