Would you like email updates of new search results? 4, 5 Right ventricular failure occurs in 25% of patients after left ventricular assist device insertion, thus the advent of Impella RP. Epub 2020 Dec 28. Transthoracic echocardiography should be used to visualize the device. The power connections for the pump motor and sensors are . The purpose of this review is to describe how to manage, reposition, and wean patients from the Impella catheter. 0000004020 00000 n Introduction. Diagnostic cardiac catheterization and coronary angiography performed at the referring facility showed severe triple vessel coronary disease and high-grade lesions in 2 SVGs. Free shipping for many products! Keyword Highlighting Cardiogenic shock - Impella 2.5, CP, 5.0, LD - Temporary VAD for less than or equal to 4 days: 2.5, CP - Temporary VAD for less than or equal to 14 dyas: 5.0, LD The Impella TM Device. Fluoroscopic image of Impella 2.5 in place in the aorta. Patel SM, Lipinski J, Al-Kindi SG, et al. Suction events may be caused by inadequate LV filling or incorrect Impella positioning with inlet area obstruction by a cardiac structure. Notably, the device manufacturer suggests measuring catheter depth from the aortic annulus to the middle of the echolucent inlet area, (i.e., 0.5 cm more than the distances stated above). To monitor the severity of hemolysis we recommend daily monitoring of serum creatinine, and plasma-free hemoglobin (PFH) or lactate dehydrogenase (LDH). Mechanical Circulatory Support for Acute Heart Failure Complicated by Cardiogenic Shock. The Impella 2.5 device is an alternative to an IABP that may be beneficial in some patients who need hemodynamic support. If Impella malposition is suspected, use echo to look for inlet or outlet obstructions. Cardiogenic shock; Impella; Mechanical support devices; intra-aortic balloon pump; mechanical circulatory support; percutaneous ventricular assist device. Hear the stories of patients and explore the latest innovations in Impella technology. It reduces myocardial oxygen consumption, improves mean arterial pressure, and reduces pulmonary capillary wedge pressure.2 The Impella provides a greater increase in cardiac output than the IABP provides. Epub 2021 Dec 20. (Figure 3F). The Impella RP is a right ventricular (RV) support system that is percutaneously positioned in the pulmonary artery via the femoral vein under fluoroscopy. Nalluri N, Patel N, Saouma S, Anugu VR, Anugula D, Asti D, Mehta V, Kumar V, Atti V, Edla S, Grewal RK, Khan HM, Kanotra R, Maniatis G, Kandov R, Lafferty JC, Dyal M, Alfonso CE, Cohen MG. Visit Suction alarms can occur if the performance level is too high for the patient; for example, in a patient who is hypovolemic or if the device is emptying the ventricle. Catheter position should be assessed daily and in response to unexpected clinical changes or specific device alarms. The Impella 2.5 catheter (Figure 2) contains a nonpulsatile microaxial continuous flow blood pump (Figure 3) that pulls blood from the left ventricle to the ascending aorta, creating increased forward flow and increased cardiac output. Because the patient was tolerating the procedure well after this, the physician decided to stent the second diseased SVG. Shearing of red blood cells is a common and clinically relevant problem with the Impella catheter. She was evaluated by our cardiac surgery team, who thought that she was a very high-risk candidate for surgery based on the recent fibrinolytic therapy, her renal failure, and the remote history of stroke. Results from additional clinical trials are available (Table 2), but continuing clinical trials are essential to evaluate the effectiveness of the Impella 2.5 device in various subgroups. Support was established at P8. All had poor ventricular function (ejection fraction =35%) and had PCI on an unprotected left main coronary artery or the last remaining patent coronary artery or graft. To understand the hemodynamics of a patient in cardiogenic shock receiving Impella support, a pulmonary arterial catheter is recommended.5 The overall weaning strategy is to achieve adequate organ perfusion at the lowest device power setting to minimize device-related complications and to determine candidacy for device removal. your express consent. Brenda McCulloch is a member of the Abiomed Administrative Advisory Board. Clipboard, Search History, and several other advanced features are temporarily unavailable. The performance level was increased from P0 to a maximum of P8 in a matter of minutes. Impella has been proven to be safe and may be superior to other mechanical support devices in CS. Please try after some time. 0000004641 00000 n Adequate blood flow was reestablished after the intracoronary administration of 500 g nitroglycerin. The motor current will be flattened. The device may cause calcium to break off of the aortic valve and embolize, causing stroke. Correct placement across the aortic valve is critical to avoid complications including hemolysis, suction episodes and inadequate hemodynamic support. The Impella device can be withdrawn, leaving the arterial sheath in place. The proximal port of this lumen is red. You can get a swollen uvula from infections including the flu, mononucleosis, croup, and strep throat. He was experiencing progression of his anginal symptoms, and his functional capacity was poor. In cases of heparin-induced thrombocytopenia, use of argatroban or bivalirudin in place of heparin in the purge solution has been reported to be safe and effective.2,3 Notably, a rising purge pressure may reflect thrombus formation in or around the motor. In the event of cardiac arrest, standard life-saving procedures should be followed with the caveat that the Impella should be set to power level P2 to prevent a continuous suction event. A high purge pressure alarm indicates that the purge pressure is greater than 700 mm Hg and generally indicates a kink in the tubing or catheter. Depending on the type of your infection . Fluoroscopic guidance in the catheterization laboratory or operating room is required. If the urine is red, rule out blood in the urine with a simple urinalysis . Transthoracic echocardiography showed increased contractility, and the ejection fraction was 40%. The performance level should be reduced to P2 and the physician should be notified of the need to reposition the Impella. Limit the physicians who can place and manage the device and have them proctor one another. 0000006172 00000 n Sheaths were placed in the right femoral vein, the right femoral artery, and the left femoral artery. Detailed view of distal end of Impella 2.5. The .gov means its official. Context in source publication. Notably, low native heart pulsatility may similarly trigger either the Impella Position Wrong or the Impella Position Unknown alarm, as the software cannot interpret the dampened amplitude of the placement signal and motor current (Figure 3E). ). Crit Care Med. She was taken to the catheterization laboratory, where she was found to have a significant obstruction of the left main coronary artery complicated by plaque rupture. The aortic end of the cannula houses a microaxial motor which spins an Archimedes screw impeller that draws blood through the cannula to the outlet area in the aortic root. Based on our experiences, we share the following recommendations. Patients must have some level of left ventricular function for an IABP to be effective. If TTE imaging is difficult, fluoroscopy or TEE can also be used. It is useful in patients undergoing high-risk PCIs. 2017 Nov;45(11):1922-1929. doi: 10.1097/CCM.0000000000002676. The most reliable and accurate transthoracic acoustic widow to assess catheter position is the parasternal long-axis window because it will provide a view of the catheter from an orthogonal angle of insonation (Figure 4). A console simulator is available that can be used to practice troubleshooting. At first, an effort should be made to identify and treat these conditions (Fig. The cannula appears as two bright echogenic, parallel lines, sometimes referred to as the railroad tracks, which ends at the inlet area. It is not uncommon that some patients with severe cardiac dysfunction do not readily demonstrate the ability to wean from the Impella. Hemolysis can occur in patients who are on the Impella 2.5. 0000001527 00000 n Usefulness of Impella support in different clinical settings in cardiogenic shock. Cardiogenic shock (CS) is a life-threatening condition associated with significant morbidity and mortality. Disclosure: The authors have no funding or conflicts of interest to report. 0000014939 00000 n Four hours later, after the activated clotting time was less than 150 seconds, the venous and arterial sheaths were removed and hemostasis was achieved after 40 minutes of manual compression. He was evaluated by our cardiothoracic surgery team and was deemed an extremely poor candidate for surgery. The proximal port of this lumen is yellow. Indications 1. Note: consider the diagnosis of normotensive cardiogenic shock when normal BP but rising lactate and transaminitis. Learn more about how the FDA-approved Impella, the world's smallest heart pump, is safe, effective and supports your heart during a procedure. When the Quick Set-Up is used, the 10% to 20% dextrose solution used to purge the motor is not heparinized. Heparin 9000 units was administered intravenously for anticoagulation, and the Impella 2.5 was advanced into position in the left femoral artery. The site is secure. Expert Rev Cardiovasc Ther. Optimal hemodynamic effect from the IABP is dependent on several factors, including the balloons position in the aorta, the blood displacement volume, the balloon diameter in relation to aortic diameter, the timing of balloon inflation in diastole and deflation in systole, and the patients own blood pressure and vascular resistance.3,4, The Impella 2.5 (Figure 1) aspirates up to 2.5 L/min of blood from the left ventricle and displaces it into the ascending aorta, rapidly unloading the left ventricle and increasing forward flow. The most common causes of Impella suction alarms include: malposition of the Impella, hypovolemia, RV failure, and pericardial tamponade. The cannula portion of the catheter is built with a 30 bend (except for the Impella LD, which has a straight design). A low purge pressure alarm indicates that the purge pressure to the Impella motor has decreased below 300 mm Hg. To date, we have placed an Impella 2.5 in about 40 patients. 0000007230 00000 n For this reason, we recommend a conservative approach to catheter manipulation with a the enemy of good is perfect philosophy. Heparin 7000 units was administered intravenously for anticoagulation. While the inability to provide anticoagulation is a contraindication, there is ongoing research into nonanticoagulant purge solution alternatives. A multi-beat acquisition of the catheter should be obtained while panning through the LV cavity, to avoid catheter foreshortening and consequent incorrect assessment of catheter depth. You may search for similar articles that contain these same keywords or you may Work with pharmacy and nursing staff to develop a standardized time for fluid and tubing changes. At follow-up 12 months later, the patient remained symptom-free with a normal ejection fraction of 55%. The second lumen ends near the motor above the level of the aortic valve and is used to monitor aortic pressure. Just before the patients return to the CICU, the pulmonary artery pressure decreased to 70/4148 mm Hg and the cardiac index was 2.69. Low purge pressures require immediate intervention by a critical care nurse. 2). Console and infusion pump setup requires 2 to 3 minutes to complete. An axial pump is one that is made up of impellar blades, or rotors, that spin around a central shaft; the spinning of these blades is what moves blood through the device.13 The distal tip of pigtail curve is 6F in size (Figure 4). Catheters with SmartAssist have an upgraded optical pressure sensor that directly measures aortic pressure and uses changes in motor current to infer an estimated LV pressure waveform. *; Barnett, Christopher F.; Tuli, Aakash; Vavilin, Ilan; Kenigsberg, Benjamin B. By continuing to use our website, you are agreeing to our, http://bmctoday.net/citoday/2009/09/supplement/article.asp?f=0909_supp_01.php, https://doi.org/10.1016/j.ijcard.2009.08.003, Potential Complications of Impella Therapy, Nursing Care of Patients With an Impella 2.5 for Circulatory Support, Copyright 2023 American Association of Critical-Care Nurses. Image courtesy ABIOMED Inc, Danvers, Massachusetts. If both the placement signal and motor current waveforms have minimal variability, the Impella Position Wrong alarm will display, indicating that both the inlet and outlet areas may be on the same side of the aortic valve (Figure 3B). Routine management of patients after PCI is not addressed. The recommended maximum performance level for continuous use is P8. If the catheter is incorrectly oriented, the pigtail can become caught in the mitral apparatus, a segment of the catheter may restrict mitral valve opening, or mobile portions of the mitral apparatus may be drawn into the inlet area. to maintaining your privacy and will not share your personal information without The VAD coordinators also provide valuable assistance. The pigtail attaches to a radiopaque/echogenic structure termed the teardrop which is contiguous with the inlet area, through which blood enters the ventricular end of the catheters cannula. A PFH >40 mg/dL or acute increase in either PFH or LDH suggests increasing hemolysis and warrants intervention.4 The main causes of Impella-related hemolysis are crowding or partial obstruction of the inlet or outlet areas due to poor positioning, thrombus formation in the cannula, operating at the higher range of the power settings, and subtherapeutic anticoagulation. Medicine (Baltimore). We provide 1-to-1 staffing for our patients with an Impella 2.5 until they are hemodynamically stable. When hemolysis occurs, hemoglobin level and hematocrit decrease, haptoglobin level decreases, and plasma levels of free hemoglobin increase. It is important to note that this derived ventricular pressure is not an accurate measure of the true LV pressure and thus may not directly replace the value of monitoring the pulmonary arterial capillary wedge pressure via a pulmonary artery catheter. Abiomed provides strong clinical support as well as excellent print and Web-based educational materials. Rao P, Khalpey Z, Smith R, Burkhoff D, Kociol RD: Venoarterial extracorporeal membrane oxygenation for, 7. You may be trying to access this site from a secured browser on the server. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Once perfusion goals are met and proven to be stable at power level P2, the Impella catheter should be removed. Despite these changes, her blood pressure and cardiac rhythm remained stable. Troubleshooting tips. Some error has occurred while processing your request. 2. position is wrong. More blood products were administered to patients treated with the Impella. The alarm will read pump position unknown due to low pulsatility. The Impella console is not able to determine the pump position because the patients systolic and diastolic pressures are not very different. The catheter depth is defined as the distance from the aortic annulus to the ventricular end of the cannula (Figure 4). A newer option that is now available for select patients is the Impella 2.5, a short-term partial circulatory support device or percutaneous ventricular assist device (VAD). Methods Cardiogenic shock was induced by injecting microspheres in the left main coronary artery in 18 adult Danish Landrace pigs. The purpose of this review is to comprehensively describe our strategy for managing, repositioning, and weaning the Impella catheter. The sheath can then be removed later when the patients activated clotting time or partial thromboplastin time has returned to near normal levels. P2 is the lowest performance level that can be used while the distal end of the Impella 2.5 is in the left ventricle. In our experience, hemolysis (45%), device-related ventricular tachycardia (18%), and limb ischemia (16%) were the most common complications, and Impella repositioning was required in 26% of cases (Table 1.). Suboptimal Impella flow and suction events can be caused by anything that reduces blood flow to the device, which is most commonly due to hypovolemia, RV failure, ventricular arrhythmias, and obstructive physiology (tamponade, pulmonary embolism, etc.). Support with Impella versus intra-aortic balloon pump in acute myocardial infarction complicated by cardiogenic shock: A protocol for systematic review and meta-analysis. 0000003906 00000 n In Europe, the Impella 2.5 has been in wide use for several years.8,9 In the United States, several small trials5,6,912 have been completed or are underway to evaluate the Impella 2.5.
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