While veno-arterial extracorporeal membrane oxygenation (V-A ECMO) has become central in the management of patients in advanced stages of cardiogenic shock due to its relative ease of deployment, there is no standardized practice for left ventricular venting. This study evaluated the relative impact of distinct left ventricular venting strategies—no venting (control), unloading (intra-aortic balloon pump or Impella CP), and offloading (Impella 5.0/5.5)—on successful device weaning and overall hospital survival. A retrospective analysis of 232 patients (2018 to 2021) with refractory cardiogenic shock was conducted, with patients matched using propensity scores based on initial Survival After Veno-artErial ECMO (SAVE) scores. Overall survival to discharge was 39% (92 of 232), with 72% of survivors achieving full neurologic recovery. Univariate analysis identified age, SAVE score, extracorporeal cardiopulmonary resuscitation status, initial lactate levels, and arterial pulsatility as primary survival predictors. After propensity matching for baseline SAVE score, the OFFLOAD configuration (Impella 5.0/5.5) significantly outperformed V-A ECMO alone. This strategy was associated with a marked increase in survival days until device removal, yielding a hazard ratio of 9.57 (95% CI 2.80 to 32.7; p <0.001). In patients with refractory cardiogenic shock, active left ventricular offloading via Impella 5.0/5.5 may facilitate more successful V-A ECMO weaning. These findings suggest that an offloading strategy provides a distinct early survival advantage compared to alternative venting configurations.