Conditions mimicking inlet obstruction (continuous or diastolic suction) resulted in an increase in MIH by 2.5 times while conditions of outlet obstruction increased MIH by 6 times. At P8, the flow rate is 1.9 to 2.6 L/min and the motor is turning at 50000 revolutions per minute. Coordination with the perfusionist is essential when patients are being placed on cardiopulmonary bypass. The Impella RP has been authorized only for the duration of the declaration that circumstancesexist justifying the authorization of the emergency use of medical devices under section 564(b)(1) of. Device profile of the Impella 5.0 and 5.5 system for mechanical circulatory support for patients with cardiogenic shock: overview of its safety and efficacy. For more information, please refer to our Privacy Policy. Abbreviations: ABGs, arterial blood gas analysis; AC, alternating current; Batt, battery; P-perf, pump performance level; PRN, as needed; PTT, partial thromboplastin time; RN, registered nurse; RPM, revolutions per minute. The Impella 2.5 catheter is placed percutaneously through the common femoral artery and advanced retrograde to the left ventricle over a guidewire. The first is to prevent clot formation on the motor, a potentially catastrophic event that is avoided by delivering a heparinized dextrose purge solution to the motor which creates a liquid interface between the motor housing and the patients blood. After advancement, always remove any slack by slowly pulling back on the catheter until cannula movement is observed. Adequate blood flow was reestablished after the intracoronary administration of 500 g nitroglycerin. 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. PMC 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. It is used for high-risk percutaneous coronary intervention and CS. Indications 1. Expert Rev Cardiovasc Ther. 0000004641 00000 n 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 Impella 2.5 is able to unload the left ventricle rapidly and effectively and increase cardiac output more than an intra-aortic balloon catheter can. The Impella controller will alarm when it determines that the device may be mispositioned or dysfunctional. 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. 0000005740 00000 n inlet should be placed approximately 3.5 cm (Impella 2.5, CP and 5.0) or 5.0 cm (Impella 5.5) distal to the aortic valve without being close to the . Our training for staff from the catheterization laboratory consisted of a 3-hour session with didactic and hands-on training. Clipboard, Search History, and several other advanced features are temporarily unavailable. modify the keyword list to augment your search. It is important to recognize that adjustments from the vascular access site are not necessarily transmitted to the cannula in a 1:1 fashion due to slack and/or torque that may exist or be introduced into the catheter. doi: 10.1097/MD.0000000000025159. The VAD coordinators also provide valuable assistance. If the urine is red, rule out blood in the urine with a simple urinalysis . The necessary images may be particularly difficult to obtain if the Impella device is medially or laterally oriented. Support with Impella versus intra-aortic balloon pump in acute myocardial infarction complicated by cardiogenic shock: A protocol for systematic review and meta-analysis. Impella 2.5 cardiac assist device in left ventricle. You can get a swollen uvula from infections including the flu, mononucleosis, croup, and strep throat. When hemolysis occurs, hemoglobin level and hematocrit decrease, haptoglobin level decreases, and plasma levels of free hemoglobin increase. When the activated clotting time was higher than 250 seconds, the Impella 2.5 was advanced into position via the left common femoral artery and placed across the aortic valve into the left ventricle. The Impella coordinator is present to assist with tubing changes as needed by the nursing staff. The SVG was aspirated before a distal protection device was placed. The use of two Impella devices concurrently has demonstrated decreased LV filling pressures and improved cardiac output for cardiogenic shock patients, although reported data on this use is limited and future studies are required. Based on our experiences, we share the following recommendations. your express consent. At P8, the flow was 2.5 L/min and the patients cardiac index was 2.58 (normal, 2.54). Because the patient was tolerating the procedure well after this, the physician decided to stent the second diseased SVG. On the placement signal screen, the waveform will show a ventricular, rather than an aortic, pressure waveform. The patients vital signs and cardiac rhythm remained stable throughout the procedure. Jo Kajewski, Advanced Impella Trainer, gives an in-depth look at managing Impella positioning using imaging. Placement monitoring screen display shows that pump position is wrong. The lesser used Impella LD is reserved for direct transaortic placement intraoperatively. The patients diastolic pressure increased significantly more with Impella support than with IABP support (P=.002). One bare metal stent (not a drug eluting stent) was placed in the SVG to the LAD. As the performance level increases, the flow rate and number of revolutions per minute increase. A culprit oriented approach should be used when troubleshooting the Impella supported patient with signs of persistent circulatory failure. To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. 0000005131 00000 n Nursing care is directed toward support of critically ill patients, including frequent hemodynamic assessment, titration of vasoactive medications as indicated, Impella console troubleshooting, and monitoring for potential complications. 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. Potential complications include bleeding, limb ischemia, hemolysis, and infection. As the Impella RP is not widely used, this review will focus only on the left-sided catheters; however, many of the concepts discussed are transitive. After any adjustment, return the power level back to the desired setting and then reassess catheter depth, orientation, and mitral valve function before tightening the Tuohy-Borst lock and making note of the final vascular access site depth. The 13F arterial sheath was sutured in placed for removal 2 hours later, after the patient had returned to the CICU. When the device has been in only for support during high-risk PCI and the patients condition is stable after the procedure is completed, rapid weaning can be done. 0000000636 00000 n In our facility, this role is filled by the interventional cardiology clinical nurse specialist. Furthermore, crowding of the inlet or outlet areas increases shear stress on the red blood cells pumped through the cannula, accelerating the rate of hemolysis caused by the device. Read below to find out how long a swollen uvula lasts and how to get treatment. Support was established at P8. Accessibility Two patients had transient hemolysis that was not clinically significant. The IABP decreases after-load, decreases myocardial oxygen consumption, increases coronary artery perfusion, and modestly enhances cardiac output.1,2 The IABP cannot provide total circulatory support. Unlike the IABP, the Impella does not require timing, nor is a trigger from an electrocardiographic rhythm or arterial pressure needed (Table 1). The catheter depth is defined as the distance from the aortic annulus to the ventricular end of the cannula (Figure 4). Potential complications of use of the Impella 2.5 are detailed in Table 3. 0000014939 00000 n hb```b``ac`a` B@EY k2T>`(zM]us:nqO8.c,BD|s+eSd:[$spK| B^0F:TXSY&D{|!3:EOT$Z^ELkzIGX;&XY All cases are also followed by the cardiac surgeon who oversees our VAD program and a critical care intensivist. All patients with this device are observed by this clinical nurse specialist during their hospital stay. Patients on Impella 2.5 support who may require interrogation of a permanent pacemaker or implantable cardioverter defibrillator present an interesting situation. 597 0 obj <> endobj xref Implementation of the ventilator bundle is required for these patients, including elevation of the head of the bed to decrease the risk of ventilator-associated pneumonia, as well as deep venous thrombosis and peptic ulcer prophylaxis. If the data suggests that the patient is over-supported, the Impella is weaned by one or two power levels. Diagnostic cardiac catheterization showed severe triple vessel disease as well as severe diffuse distal disease of his left internal mammary artery (LIMA) graft, his only remaining patent graft. The PROTECT I study was done to assess the safety and efficacy of device placement in patients undergoing high-risk PCI.10 Twenty patients were enrolled in that prospective, multicenter study. Brenda McCulloch is a member of the Abiomed Administrative Advisory Board. The Impella 2.5 can also be removed in the surgical setting with direct visualization of the common femoral artery. He was experiencing progression of his anginal symptoms, and his functional capacity was poor. 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). Epub 2021 Dec 20. 8600 Rockville Pike For this reason, we recommend a conservative approach to catheter manipulation with a the enemy of good is perfect philosophy. Weaning from the partial circulatory support provided by the Impella 2.5 can be approached in different ways. Careers. Image courtesy ABIOMED Inc, Danvers, Massachusetts. LV Aortic valve Mitral valve Impella 2.5 outlet area Impella 2.5 . Serum level of lactate was lower in patients treated with the Impella. The impellar blades of the motor could break up the thrombi, causing arterial embolization. The motor current will be flattened. 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 components required to run the device are assembled on a rolling cart (Figure 6) and include the power source, the Braun Vista infusion pump, and the Impella console (Figure 7). 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.). Mechanical Circulatory Support for Acute Heart Failure Complicated by Cardiogenic Shock. At the end of rapid weaning, the Impella device can then be removed as described in the next section. Low purge pressures require immediate intervention by a critical care nurse. A multidisciplinary approach to establishing a program for the Impella is useful in ensuring competency and good outcomes for patients. 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. Based upon these metrics we make changes to the device power level, inopressor dose, afterload reduction regimen, and diuresis goals as indicated to maintain sufficient but not excessive cardiac support while optimizing RV and LV filling pressures. An additional method to ensure proper depth is to interrogate the aortic root with color Doppler from the parasternal long-axis view. Our practice of monitoring and managing RV function relies heavily on invasive hemodynamics and ultrasound imaging. Garan AR, Kanwar M, Thayer KL, et al. Ongoing practice is essential to develop and maintain competency. An SvO2 pulmonary artery catheter showed that the patients baseline pulmonary artery pressures were markedly elevated at 69/4047 mm Hg (normal: 2030/812 mm Hg; mean, 25 mm Hg). The Impella catheter connects to a bedside controller that displays data about device performance, powers the motor, and delivers a heparinized dextrose solution (purge fluid) to the motor housing. The most common include suction, low purge pressure, and high purge pressure alarms. The Impella is placed percutaneously, most commonly via the femoral or axillary artery, into the aorta, and across the aortic valve. The Suction alarm is triggered when sudden decreases in the placement signal pressure occur in association with lower than expected flows. Now that youve read the article, create or contribute to an online discussion about this topic using eLetters. Abdullah KQA, Roedler JV, Vom Dahl J, Szendey I, Haake H, Eckardt L, Topf A, Ohnewein B, Jirak P, Motloch LJ, Wernly B, Larbig R. PLoS One. Following this trial, the Impella 2.5 device received its 510(k) approval from the Food and Drug Administration. Conversely, lack of expected pulsatility in the placement signal and/or in the motor current signal may reflect a problem.