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A 54-year-old man with previous history of coronary artery disease, was admitted to our Cardiac Intensive Care Unit for out-of-hospital refractory cardiac arrest. At arrival, the patient was intubated and under mechanical external chest compression, and was promptly supported with veno-arterial extracorporeal membrane oxygenation (V-A ECMO) and intra-aortic balloon counterpulsation (IABP). The next day, the patient was awake and neurological examination was unremarkable; coronary angiography showed left main ulcerated plaque, treated with implantation of two drug eluting stents. During the procedure, IABP was upgraded to femoral Impella 2.5 to maximize left ventricle unloading. After 10 days, the attempt to wean from V-A ECMO failed due to acute pulmonary edema, therefore femoral Impella 2.5 was upgraded to Impella 5.0 via axillary surgical access. With Impella providing 4.4 L/min, it was possible to remove V-A ECMO the day after. During the following month, the patient was progressively weaned from mechanical ventilation and mobilized, but failed in showing myocardial recovery with persistent severe left ventricular dysfunction and was then referred for Heart Transplantation.

Concomitant use of Impella while on peripheral veno-arterial extracorporeal membrane oxygenation: de-escalate and ambulate.