Background Bedside insertion of Impella percutaneous ventricular assistant device (pVAD) (Abiomed, Danvers, MA) under transesophageal echocardiographic (TEE) guidance is an attractive strategy enabling lifesaving treatment in patients with cardiogenic shock and who cannot to be transported promptly to the catheterization laboratory (Cathlab). Methods In this retrospective, single-center study, we reviewed all consecutive patients supported with Impella pVAD for CS. We compared the characteristics and outcomes of those who underwent Impella pVAD insertion under fluoroscopic guidance (Fluoro group) in the Cathlab with those who underwent insertion under TEE guidance at bedside (TEE group). Results: Between February 2013 and April 2018, a total of 150 consecutive patients with CS were supported with Impella. Fifty-five (38%) were in TEE group and 95 (62%) in Fluoro group. Impella insertion was successful in all the patients. At the time of Impella insertion patients among the TEE group had higher incidence of refractory hemodynamic collapse (87% vs 53%; p < 0.001) and venoarterial extracorporeal membrane oxygenation (62% vs 35%, p=0.002). In-hospital mortality was significantly higher in the TEE group (55% vs. 31%, p=0.04). Rates of Impella-related complications were not different between the two groups, except for higher requirement for renal replacement therapy in the TEE group (35% vs 17%; p = 0.004). Conclusions Emergent Impella insertion with TEE guidance is feasible, safe and effective in critically ill patients with cardiogenic shock.