ECLS-SHOCK is the largest randomized control trial on Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) in Acute Myocardial Infarction-related Cardiogenic Shock (AMI-CS). Unfortunately, ECLS-SHOCK failed to demonstrate a reduction of mortality in AMI-CS with VA-ECMO. Interpretation of these findings must account for frequent crossover to VA-ECMO or other temporary mechanical circulatory support (tMCS) devices in the control group, as well as the exceptionally high severity of illness among participants. We detail here point by point what could explain the outcomes and the unanswered questions. In the light of these results, a liberal use of VA-ECMO might be avoided. Further trials are needed to refine patient selection criteria and determine the optimal timing ("sweet-spot") for VA-ECMO implementation. Current practice and future guidelines will have to take in count ECLS-SHOCK results.