VA-ECMO provides critical cardiopulmonary support but increases left ventricular afterload, potentially leading to left ventricular distension (LVD). This literature review explores various clinical, hemodynamic, and imaging-based triggers for mechanical LV unloading. Findings highlight significant variability in defining LVD and initiating mechanical unloading. The study underscores the need for standardized criteria to optimize patient outcomes while minimizing risks associated with invasive procedures.