Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is applied for the treatment of cardiogenic shock. Concomitant left ventricular unloading (LVU) with a microaxial flow pump (mAFP) enables myocardial and pulmonary recovery and may overcome some of the limitations of VA-ECMO. The study included 145 cardiogenic shock patients, 89 (61.4%) of whom were treated with VA-ECMO alone (ECMO group), whereas 56 (38.6%) received LVU with a surgically implanted mAFP on top of VA-ECMO (ECMELLA group). After 2:1 propensity score matching, 30 day and 1 year survival was similar between the groups (p = 0.62 and 0.68, respectively). In the subgroup analysis, patients who received mAFP in the first 2 hours after VA-ECMO implantation had an improved 30 day (hazard ratio [HR]: 0.45 [95% confidence interval {CI}: 0.23–0.88], p = 0.02) and 1 year survival (HR: 0.52 [95% CI: 0.28–0.97], p = 0.04). The rate of limb ischemia, hemorrhage, and renal replacement therapy were comparable between the propensity score-matched cohorts. Early LVU with a surgically implanted mAFP in patients on VA-ECMO improved short-and long-term survival.