Retract the device until diastolic pressures normalizes. %PDF-1.4 % We recommend the following steps to optimize imaging: minimize the depth and narrow the sector width to the target field of view, angle the ultrasound probe to achieve a horizontally oriented view of the cannula, and adjust the gain to best highlight the target structures. All cases are also followed by the cardiac surgeon who oversees our VAD program and a critical care intensivist. The https:// ensures that you are connecting to the Explore Impella Technology - Abiomed Adequate blood flow was reestablished after the intracoronary administration of 500 g nitroglycerin. When the physician is ready to discontinue the Impella 2.5 catheter, the groin dressing should be removed, the site cleansed with chloroprep, and the sutures clipped. Arterial repair is done at that time, and the incision is covered with a sterile dressing. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Coordination with the perfusionist is essential when patients are being placed on cardiopulmonary bypass. 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. Disclosure: The authors have no funding or conflicts of interest to report. Based on our experiences, we share the following recommendations. The 13F arterial sheath was sutured in placed for removal 2 hours later, after the patient had returned to the CICU. Suction events are mostly due to abnormal device position or insufficient preload. The device received 510(k) clearance from the Food and Drug Administration in June 2008 for providing up to 6 hours of partial circulatory support. / However, in our experience, measuring structures that can be directly visualized with ultrasound is a more practical and reproducible strategy, and thus we recommend measuring from the aortic annulus to the end of the railroad tracks. The Impella should not be used in patients with a heavily calcified aortic valve. a1 Transthoracic echocardiography showed increased contractility, and the ejection fraction was 40%. The left main lesion was crossed, and one stent was deployed at the lesion. 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. The heparinized saline is placed in a pressure bag that is inflated to 300 mm Hg. 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. : Survey of anticoagulation practices with the, 3. bXSG. The Impella 2.5 cannot be used on all acutely ill patients who require hemodynamic support.14 Because the device is designed to sit across the aortic valve in the left ventricle, it should not be used in patients who have prosthetic aortic valves, so as to prevent damage to the valve. We review Impella and other percutaneous devices such as intra-aortic balloon pump, TandemHeart, and extracorporeal membrane oxygenation (ECMO) and the evidence supporting their use in the setting of CS. Crowley J, Cronin B, Essandoh M, DAlessandro D, Shelton K, Dalia AA: Transesophageal echocardiography for, 2. The catheter is then pulled back from the left ventricle into the ascending aorta and then completely withdrawn. 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. Impella ventricular support in clinical practice: Collaborative Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints@aacn.org. 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. Pahuja M, Hernandez-Montfort J, Whitehead EH, Kawabori M, Kapur NK. 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. In our case, the Impella had already been confirmed to be in the appropriate position. 0000014939 00000 n The typical infusion rate for the purge fluid is 7 to 20 mL/h. 29. 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. Fluoroscopic image of Impella 2.5 in place in the aorta. 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. The performance level should be reduced to P2 and the physician should be notified of the need to reposition the Impella. 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. A culprit oriented approach should be used when troubleshooting the Impella supported patient with signs of persistent circulatory failure. Please try after some time. 1. Additionally, I share our experiences as we developed our Impella program at our community hospital. Introduction: In one trial5 in which an IABP was compared with an Impella in cardiogenic shock patients, after 30 minutes of therapy, the cardiac index (calculated as cardiac output in liters per minute divided by body surface area in square meters) increased by 0.5 in the patients with the Impella compared with 0.1 in the patients with an IABP. Impella heart pumps have been tested under simulated conditions of inflow and outflow obstruction. The trials primary end point of hemodynamic improvement was defined as improved cardiac index at 30 minutes after implantation. 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. In our facility, physicians who can place this device are those who have interventional cardiology and/or cardiac surgery privileges. A low purge pressure alarm indicates that the purge pressure to the Impella motor has decreased below 300 mm Hg. An enlarged uvula is often caused by infection, an allergic reaction, or irritation from chemicals or medical procedures. After making note of the catheter depth from the vascular access site, the nonimager should then loosen the vascular access site Tuohy-Borst lock (Figure 5) and rotate, advance, or withdraw the catheter as appropriate to optimize its position. Develop a nursing protocol that outlines key strategies in patient management and a specific flow sheet (Figure 10) for documentation. Context in source publication. IABP therapy has been in use since the late 1960s and has been widely used in clinical practice since that time. The VAD coordinators also provide valuable assistance. (Figure 3F). 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 symptoms usually last about four to seven days and don't typically require a trip to the healthcare provider, unless it affects an infant or if complications develop. This arrangement ensured that new purge fluid was ready when needed and that the nurses had more staffing resources to assist with the tubing change. In this article, I discuss the Impella 2.5, review indications and contraindications for its use, delineate potential complications of the Impella 2.5, and discuss implications for nursing care for patients receiving extended support from an Impella 2.5. She had no further chest pain during her hospitalization and was discharged home in stable condition 3 days later. Unable to load your collection due to an error, Unable to load your delegates due to an error. Ann Transl Med. A 63-year-old woman was admitted to our facility with an acute anteroseptal myocardial infarction. Once the imager has a nonforeshortened image of the catheter in the parasternal long-axis view, the Impella motor speed should be temporarily set to power level P2, which reduced the risk of damaging the submitral apparatus during the catheter manipulation. Immediately before removal of the device, decrease the performance level to P0. Mechanical Circulatory Support for Acute Heart Failure Complicated by Cardiogenic Shock. A fluid challenge test can be useful in difficult cases. 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. The use of inotropic agents and vasopressors was similar in both groups of patients. 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. 0000003906 00000 n Heparin 9000 units was administered intravenously for anticoagulation, and the Impella 2.5 was advanced into position in the left femoral artery. A broad mosaic color Doppler pattern caused by artifact from the motor will be seen, which should be limited to the aortic side of the valve. At the end of rapid weaning, the Impella device can then be removed as described in the next section. Repositioning is best performed under fluoroscopic guidance, whenever possible. Percutaneous Mechanical Circulatory Support Devices for High-Risk Percutaneous Coronary Intervention. $L"$ As with all current forms of MCS, device-related complications remain a major concern, many of which can be mitigated by adhering to a few fundamental concepts in device management. SmartAssist technology on the Impella CP or Impella 5.5 devices can help with this as well. Hemolysis can be mechanically induced when red blood cells are damaged as they pass through the microaxial pump. 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. trailer <<4E9C4E69F2794E779C95DF45DA44CC4E>]/Prev 560917/XRefStm 1133>> startxref 0 %%EOF 613 0 obj <>stream While the inability to provide anticoagulation is a contraindication, there is ongoing research into nonanticoagulant purge solution alternatives. 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 experiencing progression of his anginal symptoms, and his functional capacity was poor. The necessary images may be particularly difficult to obtain if the Impella device is medially or laterally oriented. The hemodynamic effects of the Impella catheter are to improve systemic perfusion and provide ventricular unloading in the setting of high-risk percutaneous coronary intervention and in the treatment of cardiogenic shock. 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. The placement signal will show depressed cardiac function, evidenced by a damped appearing waveform. Sheaths were placed in the right femoral vein, the right femoral artery, and the left femoral artery. A console simulator is available that can be used to practice troubleshooting. Unauthorized use of these marks is strictly prohibited. Xbao}*"&st V4qZz A Review of the Impella Devices | ICR Journal : Increased plasma-free hemoglobin levels identify hemolysis in patients with, 5. Image courtesy Sutter Medical Center, Sacramento, California. 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. In cases where transesophageal ultrasound is used for catheter placement or repositioning, the midesophageal long-axis view (120) is the most reliable and accurate to assess catheter depth. Quick Reference and Troubleshooting Guide Rao P, Khalpey Z, Smith R, Burkhoff D, Kociol RD: Venoarterial extracorporeal membrane oxygenation for, 7. MeSH The Impella 2.5 device is an alternative to an IABP that may be beneficial in some patients who need hemodynamic support. One bare metal stent (not a drug eluting stent) was placed in the SVG to the LAD. Catheter position should be assessed daily and in response to unexpected clinical changes or specific device alarms. If you have a swollen uvula, you may also be experiencing a sore throat, trouble swallowing, and maybe even a fever. The Suction alarm is triggered when sudden decreases in the placement signal pressure occur in association with lower than expected flows. Following this trial, the Impella 2.5 device received its 510(k) approval from the Food and Drug Administration. You may be trying to access this site from a secured browser on the server. Diastolic LV numbers are also very negative and the Max and Min flows displayed on the console are lower than expected.