Background Impella support during Posterior Vein Isolation/Posterior Wall Isolation (PVI/PWI) in the setting of persistent cardiogenic shock due to refractory atrial fibrillation with rapid ventricular response (AF/RVR), to the best of our knowledge, has not been reported in the literature. Case A 61-year-old male trucker was admitted with acute HFrEF with AF/RVR 130 – 150 bpm. EF was 20% with global hypokinesis. He was diuresed and cardioverted to sinus rhythm and a QTc of 532 msec. He reverted to AF/RVR in less than 24 hours and requiring amiodarone drip but was discontinued due to severe intolerance. Subsequently, he developed cardiogenic shock, worsening cardiorenal syndrome, and shock liver requiring continuous renal replacement therapy (CRRT) in the CCU. Inotropes and vasopressors were contraindicated. AV node ablation was refused because he wanted to return to truck driving. Right heart catheterization showed PASP 53, PADP 38, and PCWP 37 with RAP 28mmHg. Coronary angiogram was normal. An Impella device was inserted, with P6 support at 3.4 L/min cardiac output. PVI with cryoablation, PWI, and anterior mitral isthmus ablation was successful with RFA. There was a complete exit block 30 mins after ablation. Normal sinus rhythm was restored after cardioversion. Echocardiography 48 hours later revealed improvement in EF from 10% to 40% in sinus rhythm. Follow up six months in the clinic showed EF recovery to 62%. Conclusion This case report demonstrates that in patients with refractory atrial fibrillation causing cardiogenic shock, PVI/PWI, while on Impella support, could be a good treatment option.