VA plus Impella, LV still loaded

Handover

VA-ECMO at 4.5 L for refractory shock. Someone dropped in an Impella CP at P-2 “for unload” and left. PCWP 28, pulse pressure 4, smoke in the LV, AV barely opening. Retrograde aortic flow is the afterload. A token P-2 is not an unload. Titrate the Impella — and do not climb into an empty cavity if VA over-drains.