Combined veno-venous ECMO and direct aortic impella 5.5 support enabling emergency mitral valve replacement in acute severe mitral regurgitation with fulminant pulmonary edema.

Acute severe mitral regurgitation (MR) can cause cardiogenic shock and fulminant pulmonary edema. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) may worsen pulmonary congestion by increasing left ventricular afterload. We report a 61-year-old man with acute severe MR and extreme respiratory failure (FiO₂ 1.0: pH 7.144, PaO₂ 48 mmHg, PaCO₂ 101 mmHg) who underwent emergency mitral valve replacement. Because severe pulmonary edema and post-cardiotomy shock compromised separation from cardiopulmonary bypass, an Impella 5.5 was inserted via a direct aortic graft, followed by veno-venous (VV) ECMO. This combined support enabled decoupled circulatory and respiratory stabilization. Although substantial vasoactive and inotropic support was initially required, systemic perfusion was maintained and subsequently stabilized with Impella-mediated antegrade flow without conversion to VA- or V-AV ECMO. Serum lactate transiently peaked at 10.9 mmol/L on postoperative day (POD) 1 and subsequently normalized as circulatory function recovered. Respiratory function and bilateral pulmonary opacities progressively improved under VV-ECMO-supported lung rest and intensive diuretic therapy. VV-ECMO was removed on POD 3, Impella on POD 6, and the patient was discharged on POD 46 without neurological sequelae. This case suggests that combined VV-ECMO and Impella support may provide an effective decoupled strategy for selected patients with concomitant severe respiratory and circulatory failure.