The application of peripheral veno-arterial extracorporeal membrane oxygenation in the management of inotrope-refractory cardiogenic shock has proven controversial because of concerns about sub-optimal drainage of the left heart, resulting in left ventricular distension and pulmonary oedema. In this article, we will discuss the pathophysiological basis and clinical implications of left ventricular distension following institution of peripheral extracorporeal life support. We will also review the clinical strategies used to circumvent left ventricular distension and pulmonary oedema in these patients.