The utilization of temporary mechanical circulatory support (tMCS) has increased significantly over the last 40 years for stabilization of salvageable patients; however, there has not been much improvement in survival when used for cardiogenic shock, which has a current mortality of around 50%.^1,2 Many efforts have been devoted to better understanding the stages of cardiogenic shock, as well as how combinations of both drugs and devices can increasingly be used to strive for recovery of the native heart.^3,4 Despite the clear and urgent need for improving outcomes, none of the clinical trials has found convincing evidence for a survival advantage using tMCS compared with other forms of care.^1,3 Therefore, new approaches to understanding the pathophysiology of cardiogenic shock, as well as novel technologies, would be beneficial.²

Veno-arterial extracorporeal membrane oxygenation (VA ECMO) is the most commonly used mode of tMCS for cardiogenic shock to efficiently provide cardiopulmonary support. Conventional VA ECMO uses continuous-flow devices to achieve circulatory support; this approach increases afterload and workload on a struggling heart, often leading to inability of the aortic valve to open and is associated with a high mortality rate even with restoration of adequate circulatory flow.^1,3,4

The complication of increased left ventricular afterload has led to recognizing the importance of unloading or venting of the left ventricle (LV) while on ECMO to avoid distension and increased wall stress. This can be achieved by using various techniques, all of which require alternative technologies and major interventions and are sometimes deployed too late.³ At a physiological level, it is hypothesized that unloading the LV could help increase the likelihood of recovery by decreasing the heart’s metabolic demands and allowing time for it to rest.