The aim of this study is to characterize ventilation/perfusion (V/Q) matching in adult patients receiving peripheral VA ECMO support while on mechanical ventilation, and to evaluate the impact of PEEP titration guided by Electrical Impedance Tomography (EIT) and esophageal pressure measurements on lung mechanics and V/Q optimization.

The investigators hypothesize that an individualized PEEP titration guided by esophageal pressure measurements and Electrical Impedance Tomography can reduce lung overdistention, enhance lung recruitment, and improve V/Q matching by optimizing regional ventilation and perfusion also in VA ECMO.

Our objectives are:

1. To describe V/Q matching in patients undergoing mechanical ventilation during peripheral VA ECMO support.
2. To explore the impact of PEEP titration based on esophageal pressure and EIT in terms of lung mechanics and V/Q matching.

Inclusion Criteria:

• Adults (≥18 years) undergoing mechanical ventilation during peripheral VA ECMO support for cardiogenic shock, cardiac arrest, or refractory heart failure.
• On ECMO support for at least 6 hours
• Swan-Ganz catheter required as standard clinical care
• Clinically stable in the estimation of the study investigator

Exclusion Criteria:

• Contraindications to EIT (e.g., presence of pacemaker or IMPELLA device for electrical interference)
• Patients without pulmonary flow (non-pulsatile pulmonary prSessure)
• Patients with known pulmonary embolism
• Imminent withdrawal of life support