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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.