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.
Kinoshita R, Watanabe T, Okaguchi K, Hirooka K • Journal of artificial organs : the official journal of the Japanese Society for Artificial Organs • 2026
Combined veno-venous ECMO and direct aortic Impella 5.5 support may provide an effective decoupled strategy for selected patients with concomitant severe respiratory and circulatory failure following emergency mitral valve replacement.
Key Findings
Background
A patient with acute severe mitral regurgitation presented with extreme respiratory failure requiring emergency mitral valve replacement.
Patient was a 61-year-old man with acute severe mitral regurgitation and cardiogenic shock
Arterial blood gas on FiO₂ 1.0 showed pH 7.144, PaO₂ 48 mmHg, and PaCO₂ 101 mmHg, indicating combined severe hypoxemic and hypercapnic respiratory failure
Condition was characterized as fulminant pulmonary edema necessitating emergency surgical intervention
Methods
Severe pulmonary edema and post-cardiotomy shock prevented successful separation from cardiopulmonary bypass, necessitating mechanical circulatory and respiratory support.
Standard separation from cardiopulmonary bypass was compromised by persistent post-cardiotomy shock and severe pulmonary edema
An Impella 5.5 was inserted via a direct aortic graft to provide left ventricular unloading and antegrade flow
Veno-venous (VV) ECMO was added to address the respiratory failure component separately from the circulatory failure
VA-ECMO was deliberately avoided because it may worsen pulmonary congestion by increasing left ventricular afterload
Results
The combined VV-ECMO and Impella 5.5 strategy enabled decoupled circulatory and respiratory stabilization without conversion to VA-ECMO or V-AV ECMO.
Systemic perfusion was maintained through Impella-mediated antegrade flow
Substantial vasoactive and inotropic support was initially required but subsequently stabilized
No conversion to VA-ECMO or V-AV ECMO was needed throughout the postoperative course
The approach allowed independent optimization of respiratory support (via VV-ECMO) and cardiac output (via Impella)
Results
Serum lactate transiently peaked at 10.9 mmol/L on postoperative day 1 and subsequently normalized as circulatory function recovered.
Peak lactate of 10.9 mmol/L on postoperative day (POD) 1 indicated significant but transient tissue hypoperfusion
Lactate normalization corresponded with recovery of circulatory function supported by the Impella
This pattern reflected the adequacy of the combined support strategy in maintaining systemic perfusion despite initial hemodynamic instability
Results
Respiratory function and bilateral pulmonary opacities progressively improved under VV-ECMO-supported lung rest combined with intensive diuretic therapy.
Bilateral pulmonary opacities resolved progressively during the postoperative course
VV-ECMO was removed on postoperative day 3
Intensive diuretic therapy was used concurrently with VV-ECMO lung rest to manage pulmonary edema
Results
The patient was successfully weaned from all mechanical support and discharged on postoperative day 46 without neurological sequelae.
Impella 5.5 was removed on postoperative day 6
VV-ECMO was removed earlier, on postoperative day 3
The patient was discharged on postoperative day 46
No neurological sequelae were reported at discharge despite the severity of the initial presentation including profound acidosis and respiratory failure
What This Means
This research describes a single patient case where doctors used two mechanical support devices simultaneously to stabilize a 61-year-old man who developed life-threatening heart and lung failure after emergency heart valve surgery. The patient had a severely leaking mitral valve that caused his lungs to fill with fluid, and his blood oxygen and carbon dioxide levels were at dangerously abnormal levels. After surgery to replace the valve, his heart and lungs were still too weak to function independently. The medical team chose not to use the most common type of heart-lung bypass device (VA-ECMO) because it can actually worsen fluid buildup in the lungs in situations like this. Instead, they combined a heart pump (Impella 5.5, inserted directly into the aorta) to support the heart, with a lung-focused bypass device (VV-ECMO) to support breathing separately.
This 'decoupled' approach allowed the doctors to treat the heart failure and respiratory failure as two independent problems with targeted devices. The patient's blood lactate levels — a marker of how well tissues are receiving oxygen — peaked at a very high level the day after surgery but then gradually returned to normal as the heart recovered. The lung support device was removed after three days, the heart pump after six days, and the patient left the hospital on day 46 with no brain damage or other neurological problems.
This research suggests that using VV-ECMO together with a direct aortic Impella 5.5 may be a viable alternative strategy for patients who have both severe heart failure and severe respiratory failure at the same time, particularly when standard approaches like VA-ECMO might make the lung problem worse. Because this is a single case report, broader conclusions cannot yet be drawn, but the case adds to the growing understanding of how different mechanical support devices can be combined in complex cardiac surgical emergencies.
Kinoshita R, Watanabe T, Okaguchi K, Hirooka K. (2026). 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.. Journal of artificial organs : the official journal of the Japanese Society for Artificial Organs. https://doi.org/10.1007/s10047-026-01592-5