Colombier S, et al. - Given the efficacy of peripheral veno-arterial extra corporeal life support (V-A ECLS) as a tool in treating refractory cardiogenic shock (RCS) and that despite additional use of intra-aortic balloon pump, insufficient left ventricular unloading may occur, researchers here report on their experience combining V-A ECLS and Impella to treat symptomatic, critical patients. In this single-center review analysis, patients with V-A ECLS and intra-aortic balloon pump for RCS and subsequently benefiting from Impella implantation were assessed. From 1,248 cases, they included 31 critical patients (2.5%) with a median SOFA score = 12 (7–15); median age: 53 years; 74% male. Myocardial ischemia and idiopathic dilated myocardiopathy were identified resulting in 52% and 23% of RCS. Diabetes, patients aged over 60 years, surgery using extracorporeal circulation, adrenalin infusion, acute myocardial infarction, and chronic HFrEF were the factors correlated with day-30 mortality. Independent risk factor for the day-30 mortality comprises chronic HFrEF. Impella and V-A ECLS combination represent a promising association for critical patients manifesting symptomatic insufficient LV unloading, for weaning V-A ECLS or testing the right ventricle before a switch to left ventricle assist device support.