We thank Dr. Inamura for his precious comments. We agree a possible “watershed” phenomenon may occur with the combined Impella and Veno-Arterial Extracorporeal Membrane Oxygenator (VA-ECMO) implantation, although no sign of Harlequin syndrome was detected in our patient. Few data currently guide the choice of mechanical support in acute myocardial infarction related cardiogenic shock. The positive effect on myocardial recovery with the Impella is mostly related to left ventricular “unloading effect”. As shown in pre-clinical models and in a pivotal study, the “unloading” may activate a cardio-protective cytokine program that reduces myocardial damage after delayed reperfusion. Increase of oxygen supply to myocardial tissue could be another possible mechanism to enhance recovery chances, so a Veno-Artero-Venous ECMO could be a reasonable escalation solution. Further investigation is needed to compare those different approaches.