Cardiogenic shock (CS) is one of the most challenging areas in cardiology, where hard evidence is often limited. Several factors contribute to this scarcity. Patients with CS are typically critically ill, with many presenting in altered mental status or being sedated, which prevents them from providing informed consent. Additionally, the relatively low incidence of CS makes it challenging to achieve large sample sizes in research studies. However, recent progress has been made with the publication of four randomized controlled clinical trials, focusing on venoarterial extracorporeal membrane oxygenation (VA-ECMO) in CS. Two of these trials examined the potential benefits of early VA-ECMO in CS: the ECMO-CS multicenter randomized trial¹ and the ECLS-SHOCK trial.² The other two trials focused on early versus as-needed left ventricular (LV) venting in patients with CS on VA-ECMO: the Early Venting versus cOnventional treatment for Left Ventricular distention during venoarterial ExtraCorporeal Membrane Oxygenation support (EVOLVE-ECMO)³ and The Early Left Atrial Septostomy Versus Conventional Approach After Venoarterial Extracorporeal Membrane Oxygenation (EARLY-UNLOAD).⁴ Disappointingly, all the trials yielded negative results, failing to demonstrate significant benefits from the respective interventions. Each trial has unique characteristics that may explain the lack of benefit from either VA-ECMO or LV venting, respectively. However, a deeper, more fundamental reason may underlie the failure of these trials. In this commentary, we will endeavor to dissect the underlying reasons for these outcomes.