It should not be used in patients with moderate to severe aortic insufficiency; it may worsen the degree of insufficiency because the aortic valve cannot close completely with the device in place. Patients on Impella 2.5 support who may require interrogation of a permanent pacemaker or implantable cardioverter defibrillator present an interesting situation. 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. The performance level should be decreased to P2 and the physician should be notified to reposition the device by pulling it back slightly to obtain an aortic waveform. Just visit www.ccnonline.org and click Respond to This Article in either the full-text or PDF view of the article. ?(x$2pD] 9A =9@w E" endstream endobj 612 0 obj <>/Filter/FlateDecode/Index[62 535]/Length 41/Size 597/Type/XRef/W[1 1 1]>>stream He was discharged home 2 days later. Comparing traditional intra-aortic balloon therapy with Impella 2.5 percutaneous ventricular assist device, Potential complications of Impella 2.5 support, Nursing care of patients with an Impella 2.5, Impella 2.5 performance level and flow rate, Physician orders for placement of Impella 2.5, Impella competency checklist for nurses in the cardiac intensive care unit: critical elements for managing patients with an Impella 2.5, Brenda McCulloch is a cardiovascular clinical nurse specialist at Sutter Heart and Vascular Institute, Sutter Medical Center, Sacramento, California. a small tube that carries blood out of the heart into a pump then blood pumped back into the aorta (LVAD) or pulmonary artery (RVAD) can be continuous flow (cf-VAD) rather than pulsatile (generally older models); cf-VADs are smaller, quieter, and durable. It is useful in patients undergoing high-risk PCIs. Our typical hemodynamic targets are a mean arterial pressure of 6070 mm Hg, a right atrial pressure of 812 mm Hg, a pulmonary arterial wedge pressure <15 mm Hg, and a cardiac index >2.0 L/min/m2. Esposito ML, Morine KJ, Annamalai SK, et al. 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. 6, 7 However, the device may migrate out of . 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). government site. 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 SyBbhD&,V}R#Ohov]F}9v_c- Visit Get new journal Tables of Contents sent right to your email inbox, Impella Management for the Cardiac Intensivist, Articles in PubMed by Alexander I. Papolos, Articles in Google Scholar by Alexander I. Papolos, Other articles in this journal by Alexander I. Papolos, A Narrative Review of Nutrition Therapy in Patients Receiving Extracorporeal Membrane Oxygenation, Use of Impella in Patients Listed for Heart Transplantation, Survival and Factors Associated with Survival with Extracorporeal Life Support During Cardiac Arrest: A Systematic Review and Meta-Analysis, Thrombosis in Extracorporeal Membrane Oxygenation (ECMO) Circuits, Heparin Versus Bivalirudin for Anticoagulation in Adult Extracorporeal Membrane Oxygenation: A Systematic Review and Meta-Analysis, Privacy Policy (Updated December 15, 2022). 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. The second lumen ends near the motor above the level of the aortic valve and is used to monitor aortic pressure. The motor current will be flattened. Our practice is to integrate clinical factors, such as mean arterial pressure, heart rate, and urine output with invasive hemodynamics, and lab dataspecifically, serum lactate and pulmonary arterial oxygen saturation every 6 hours. After a family conference that included the patient, the decision was made to proceed with high-risk PCI of the LIMA graft, using the Impella 2.5 for hemodynamic support during the procedure. 0000001133 00000 n Ongoing practice is essential to develop and maintain competency. If hemolysis is suspected, Jess offers the following troubleshooting tips: Address and correct any active position or suction alarms to help prevent hemolysis. This arrangement allows rapid initial setup of the console so that support can be initiated quickly. 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. Impella 2.5 cardiac assist device in left ventricle. There is currently no consensus on best practice regarding its use in these two distinct indications. 0000000016 00000 n 0000004122 00000 n Accessibility Signs of pulmonary congestion should be monitored, as, at least in theory, high Impella RP support with reduced LV function could cause overflow and pulmonary congestion. Reports of longer duration of therapy in both the United States and Europe have been published.8,9, The Impella 2.5 has been used for hemodynamic support during high-risk PCI and for hemodynamic support of patients with myocardial infarction complicated by cardiogenic shock or ventricular septal defect, cardiomyopathy with acute decompensation, postcardiotomy shock, off-pump coronary artery bypass grafting surgery, or heart transplant rejection and as a bridge to the next decision.9. Percutaneous mechanical support devices are placed in a minimally invasive manner and provide life-saving assistance. Please try again soon. Background and aim This study aimed to assess right ventricular (RV) function during cardiogenic shock due to acute left ventricular (LV) failure, including during LV unloading with Impella CP and an added moderate dose of norepinephrine. A low purge pressure can allow blood to enter the motor and damage the motor, rendering the device inoperable. Components of the Impella 2.5 cardiac assist device. No reflow is a phenomenon in PCI that can cause severe hemodynamic compromise because myocardial perfusion through a given segment of the coronary circulation is inadequate, yet no angiographic evidence of mechanical obstruction of the vessel is apparent.15 The patients pulmonary artery pressures increased to 93/4058 mm Hg and the cardiac index decreased to 2.2. The .gov means its official. Percutaneous Mechanical Circulatory Support Devices for High-Risk Percutaneous Coronary Intervention. There are two indications for anticoagulation when using the Impella catheter. Like all LV assist devices, the Impella can only pump as much blood as is available to it. Expert commentary: The Impella catheter has become a common MCS device used in medical and surgical cardiac intensive care units, and as such intensivists must have a core competency with its management. Because the patient was tolerating the procedure well after this, the physician decided to stent the second diseased SVG. The use of continuous cardiac output monitoring may be useful for patients with cardiogenic shock. Brenda McCulloch; Use of the Impella 2.5 in High-Risk Percutaneous Coronary Intervention. Patients who undergo high-risk percutaneous coronary intervention (PCI), such as procedures on friable saphenous vein grafts or the left main coronary artery, may have an intra-aortic balloon catheter placed if they require hemodynamic support during the procedure. : Simultaneous venoarterial extracorporeal membrane oxygenation and percutaneous left ventricular decompression therapy with, 8. Depending on the type of your infection . For continued use, the purge fluid is heparinized (50 units heparin per milliliter of fluid) and infused via an integrated infusion pump, the Braun Vista infusion pump (Figure 5). After careful evaluation and optimization of pharmacological therapy for heart failure, the decision was made to proceed with high-risk PCI of the SVG to the left anterior descending (LAD) artery with an Impella 2.5 used to provide partial circulatory support during the PCI. The Impella (Abiomed Inc.) is an axial flow pump on a pigtail catheter that is placed across the aortic valve to unload the left ventricle by delivering non-pulsatile blood flow to the ascending aorta. The placement signal will display either an aortic pressure waveform (correct position) or ventricular pressure waveform (incorrect position) depending on the position of the fiber-optic sensor. Pahuja M, Hernandez-Montfort J, Whitehead EH, Kawabori M, Kapur NK. If you have a swollen uvula, you may also be experiencing a sore throat, trouble swallowing, and maybe even a fever. Patients in cardiogenic shock supported by venoarterial extracorporeal membrane oxygenation (VA-ECMO) often require an LV unloading strategy to prevent the development of pulmonary edema, thrombus formation in the LV, and reduce LV wall stress.6 The concurrent use of VA-ECMO with the Impella catheter as an unloading strategy (ECPELLA) has become a popular MCS configuration associated with improved cardiogenic shock outcomes over VA-ECMO alone.7 The management of the Impella catheter while in the ECPELLA configuration is no different than described elsewhere in this review. During this time, transient no-reflow developed. 0000005131 00000 n With the physician at the bedside, transthoracic echocardiography is performed and the pumps performance level is decreased. 2020 Jul;8(13):835. doi: 10.21037/atm.2020.03.152. 2022 Feb 28;19(2):115-124. doi: 10.11909/j.issn.1671-5411.2022.02.003. 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. Rolling cart carrying components required to run the Impella 2.5. Impella use in real-world cardiogenic shock patients: Sobering outcomes. That waveform depicts the pressure gradient across the intra- and extraluminal surface of the cannula, and when the device is correctly positioned, the intra- and extraluminal pressures reflect the pressure within LV and aortic root, respectively. A console simulator is available that can be used to practice troubleshooting. The Impella RP is a right ventricular (RV) support system that is percutaneously positioned in the pulmonary artery via the femoral vein under fluoroscopy. If Impella malposition is suspected, use echo to look for inlet or outlet obstructions. The nursing care of patients remaining on Impella 2.5 support requires astute assessment and expert nursing care (Table 4). The Impella TM Device. Adequate blood flow was reestablished after the intracoronary administration of 500 g nitroglycerin. The patients diastolic pressure increased significantly more with Impella support than with IABP support (P=.002). The Impella 2.5 catheter shaft size is 9F and is 12F at its largest point, which is the microaxial blood pump. One patient died before implantation of a device. The question that then arises is when to favor escalating inotropes to assist in device weaning. MeSH 1. your express consent. While there is little data to draw from, it follows that inotropes should be minimized or avoided in patients with unrevascularized coronary disease or active ischemia. Correct placement across the aortic valve is critical to avoid complications including hemolysis, suction episodes and inadequate hemodynamic support. The console can run on a fully charged battery for up to 1 hour. 2020 Jan 22;2(1):23-44. doi: 10.36628/ijhf.2019.0015. Expert Rev Med Devices. National Library of Medicine The left main lesion was crossed, and one stent was deployed at the lesion. Routine management of patients after PCI is not addressed. We follow our hospitals protocol for achieving hemostasis, using either manual or mechanical compression. Bookshelf The Suction alarm is triggered when sudden decreases in the placement signal pressure occur in association with lower than expected flows. 3. placement monitoring is suspended or disabled. The impellar blades of the motor could break up the thrombi, causing arterial embolization. (NOTE: While the illustrations in this document depict the Impella 2.5 Catheter, the information presented also applies to the Impella 5.0 Catheter and Impella LD Catheter.) At follow-up 12 months later, the patient remained symptom-free with a normal ejection fraction of 55%. If the device advances too far and both the inflow and outflow areas are fully in the left ventricle, the pump position wrong alarm will occur. 8600 Rockville Pike An additional method to ensure proper depth is to interrogate the aortic root with color Doppler from the parasternal long-axis view. eCollection 2021. Support with Impella versus intra-aortic balloon pump in acute myocardial infarction complicated by cardiogenic shock: A protocol for systematic review and meta-analysis. Slow weaning is accomplished by decreasing the performance level by 1 or 2 levels every 2 or 3 hours. As the patient goes on cardiopulmonary bypass, the performance level of the Impella must be decreased. Unable to load your collection due to an error, Unable to load your delegates due to an error. Expert Rev Cardiovasc Ther. Inotropic agents, such as dobutamine and milrinone, and vasopressors, such as dopamine and norepinephrine, may still be needed after the Impella 2.5 is placed to maintain a cardiac index of at least 2 and systolic blood pressure at 90 mm Hg or higher. Six weeks later, the patient was pain free with no complaints of dyspnea. 0000003906 00000 n Impella heart pumps (Abiomed) are intravascular microaxial blood pumps that provide temporary MCS during HRPCI or in the treatment of cardiogenic shock. and transmitted securely. The performance level should be reduced to P2 and the physician should be notified of the need to reposition the Impella. Patel SM, Lipinski J, Al-Kindi SG, et al. The 13F arterial sheath was sutured in placed for removal 4 hours later after the patient was returned to the CICU. Data is temporarily unavailable. The morphology of the placement signal resembles that of an arterial waveform, which can be counterintuitive as the peak of the waveform occurs in diastole when the gradient between the LV and aorta is greatest, whereas the nadir occurs during systole when it is least. Additionally, patients are observed by the VAD coordinator. Int J Heart Fail. 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). Subramaniam AV, Barsness GW, Vallabhajosyula S, Vallabhajosyula S: Complications of temporary percutaneous. If the patient tolerates this slow weaning by remaining hemodynamically stable while at P2, the device is then removed. Shearing of red blood cells is a common and clinically relevant problem with the Impella catheter. Potential complications of use of the Impella 2.5 are detailed in Table 3. Indications 1. Despite the no-reflow, the arterial pressure, heart rate, and cardiac rhythm remained stable, and the patient had no complaints of shortness of breath or chest discomfort. He had a long history of diabetes and had undergone coronary artery bypass surgery 20 years prior.

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