This systematic review and meta-analysis evaluates the efficacy of left-ventricular (LV) unloading with Impella, compared to standard venoarterial extracorporeal membrane oxygenation (VA-ECMO), during extracorporeal cardiopulmonary resuscitation (ECPR) for refractory cardiac arrest. Analyzing data from 1014 patients across 32 hospitals, the study finds that ECMELLA (combined Impella and VA-ECMO) is associated with improved survival and neurological outcomes, especially in patients with acute myocardial infarction, compared to VA-ECMO alone. Despite a higher rate of complications, ECMELLA shows promise in enhancing patient recovery, underscoring the need for standardized guidelines for its use in ECPR.