Patients who develop cardiogenic shock (CS) while awaiting heart transplantation (HTX) have a high mortality. Previously they were supported by ECMO or durable LVAD. We changed our approach to bridge these patients to HTX (BTT) with Impella 5.5 (IMP5.5) for circulatory support and rapid left ventricular unloading with the intention to recover organ dysfunction and allow for ambulation. We report the results of our novel treatment strategy. Data was obtained by retrospective chart review of 22 patients treated with IMP5.5 as BTT from 3/2020 - 7/2022. Eligibility for IMP5.5 placement required meeting UNOS criteria for CS. The approach is based on the following concept: 1) IMP5.5 placement via the axillary artery 2) IMP5.5 use regardless of right ventricular (RV) function and pulmonary resistance (PVR) 3) Addition of inotropes and diuretics for RV support and reduction of PVR if needed 4) Anticoagulation with systemic argatroban and D5/bicarbonate through the purge to prevent the development of heparin induced thrombocytopenia (HITT) 5) Frequent independent ambulation. 19 (86%) patients received HTX after mean 18.3 +/- 14.9 days (range 2-71) of IMP5.5 support. No patient required placement of a RVAD. Reversal of elevated PVR occurred in 21 patients (95%). 3 (14%) patients received LVAD due to either patient's preference (n=1), non-disabling stroke (n=1), or high PVR (n=1)). All transplant recipients survived to discharge and remain alive with mean follow-up 518 +/- 240 days (range 194 - 946). All LVAD recipients remain alive with mean follow-up 286 +/- 193 days (range 90 - 476). On IMP5.5 support, no relevant hemolysis, HITT or renal failure occurred. All patients ambulated independently >250 m/day pre HTX or LVAD. Complications: localized axillary hematoma (n=4), non-disabling embolic stroke (n=1), GI bleed (n=1). Post HTX mean length of stay in ICU was 8 +/- 7 days (range 4 - 33) and 15 +/- 11 days (range 8 - 58) in hospital. Our management strategy for transplant eligible patients presenting in CS resulted in 100% survival pre- and post-HTX with minimal complications. Length of ICU and hospital stay after HTX are shorter than in recently published UNOS data. These results may be due to pre-transplant rehabilitation on IMP5.5 support facilitating organ function recovery and reversal of elevated PVR. [ABSTRACT FROM AUTHOR]