“…Gaisendrees et al, described that ECPELLA timing was determined by levels of LV distension, blood retention within the LV cavity (spontaneous contraction by echocardiography), and pulmonary edema due to increased afterload by VA-ECMO. 13 In contract, we established ECPELLA support at the earliest time point immediately after the establishment of E-CPR to obtain a VA-ECMO perfusion index ≥ 2.2 L/min/m 2 preventing the aortic valve opening in which Impella was used to directly pump out the blood from the LV cavity increasing total MCS flow (total LV support) 15 Further studies are necessary whether reduction of acute kidney injury is associated with ECPELLA support timing, higher total circulatory support flow, and/or arterial perfusion pressure.…”