The patients diastolic pressure increased significantly more with Impella support than with IABP support (P=.002). Routine management of patients after PCI is not addressed. Assign a point person who can oversee and coordinate the program. Impella ventricular support in clinical practice: Collaborative Ten different performance levels ranging from P0 to P9 are available (Table 5). The Suction alarm is triggered when sudden decreases in the placement signal pressure occur in association with lower than expected flows. Adequate blood flow was reestablished after the intracoronary administration of 500 g nitroglycerin. 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. The left main lesion was crossed, and one stent was deployed at the lesion. Based on our experiences, we share the following recommendations. The most common causes of Impella suction alarms include: malposition of the Impella, hypovolemia, RV failure, and pericardial tamponade. 2021 Feb;19(2):151-164. doi: 10.1080/14779072.2021.1863147. MeSH The purpose of this review is to comprehensively describe our strategy for managing, repositioning, and weaning the Impella catheter. If the data suggests that the patient is over-supported, the Impella is weaned by one or two power levels. The aortic valve symbols will not be seen on the placement monitoring diagram. Now that youve read the article, create or contribute to an online discussion about this topic using eLetters. eCollection 2021. and transmitted securely. Standard therapeutic anticoagulation targets are; an activated clotting time of 160180 sec, a heparin antifactor Xa of 0.3-0.5, and/or activated partial thromboplastin time of 6090 sec. 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. This should prompt urgent ultrasound assessment as the device may need to be either retracted or advanced. Three sequential stents were placed in the area of disease. Free shipping for many products! Regular repositioning of patients and assessment of their skin are necessary to prevent skin breakdown. Hemolysis can occur in patients who are on the Impella 2.5. 0000003906 00000 n 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. The Impella RP can be used in tandem with a left-sided Impella device. The Impella 2.5 should not be used in patients with aortic valve disease or known left ventricular thrombus. In the Impella LD, 5.0, and RP, the placement signal is a differential pressure waveform that is measured from the differential pressure sensor. In general, if the patient subsequently develops oliguria, tachycardia, lactate >2 mg/dL, or a cardiac index <2.0 L/min/m2 we will resume the prior level of cardiac support provided by the Impella. bXSG. The catheter device was connected to the Impella console and support was initiated. If a significant color Doppler signal is observed below the valve (in the absence of significant aortic regurgitation), the device is likely too deep. doi: 10.1371/journal.pone.0247667. As the patient goes on cardiopulmonary bypass, the performance level of the Impella must be decreased. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Notably, catheter position is best assessed ultrasonographically, as radiography does not accurately identify the cannula position relative to cardiac anatomic structures. Using the LV Waveform to Troubleshoot Suction Events - Heart Recovery %PDF-1.4 % The structural design of each of these LV support catheters is grossly similar (Figure 2). Arterial repair is done at that time, and the incision is covered with a sterile dressing. The size and function of the left and right ventricles as well as interventricular septal position should also be assessed, as low flow and suction alarms can be caused by over-decompression of the LV, RV failure, and/or obstructive physiology. The most common Impella-related complications reported are hemolysis, embolic stroke, limb ischemia, access site bleeding, device migration, device malfunction, motor thrombosis, ventricular arrhythmia, and mitral valve disruption.8 Most of these complications are directly related to catheter position and anticoagulation, stressing the importance of frequent clinical assessment. Impella heart pumps have been tested under simulated conditions of inflow and outflow obstruction. may email you for journal alerts and information, but is committed 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. Crit Care Nurse 1 February 2011; 31 (1): e1e16. LV Aortic valve Mitral valve Impella 2.5 outlet area Impella 2.5 . 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. All cases are also followed by the cardiac surgeon who oversees our VAD program and a critical care intensivist. The proximal port of this lumen is red. 2 main types of pumps currently used: Bookshelf Hemolysis, as measured by the plasma level of free hemoglobin, was higher in patients treated with the Impella. On arrival, his blood pressure was 151/88 mm Hg with a heart rate of 66/min. The patients hemodynamic status is assessed after every decrease in performance level. 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. Bethesda, MD 20894, Web Policies The site is secure. The second indication is to prevent clot formation on the catheter itself and potential embolization into the patient. The second lumen of the Impella 2.5 is flushed with heparinized saline (500 mL normal saline with 1000 units heparin) by using regular (not infusion pump) intravenous tubing. In our facility, physicians who can place this device are those who have interventional cardiology and/or cardiac surgery privileges. 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 . Bivalirudin was administered for anticoagulation, and the Impella 2.5 was advanced into position in the left femoral artery. 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. The console can run on a fully charged battery for up to 1 hour. Before Utilization of the Impella for hemodynamic support during percutaneous intervention and cardiogenic shock: an insight. Some facilities may use what is referred to as a preclose method while the patient is still in the catheterization laboratory; that technique uses 2 8F Perclose suture-mediated closure devices (Abbott Laboratories, Abbott Park, Illinois). 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. Hemodynamically, we typically titrate fluid balance goals and inotropes to target a right atrial pressure of 812 mm Hg and a pulmonary artery pulsatility index >1. Heparin 7000 units was administered intravenously for anticoagulation. We have 2 nurses at the bedside for the tubing change. Some were designed to support future versions of Impella catheters. To date, we have placed an Impella 2.5 in about 40 patients. Diastolic LV numbers are also very negative and the Max and Min flows displayed on the console are lower than expected. Despite these changes, her blood pressure and cardiac rhythm remained stable. 2017 Oct;14(10):789-804. doi: 10.1080/17434440.2017.1374849. The aortic annulus and the ventricular end of the cannula must be well visualized in a single image to make an accurate measurement. We provide 1-to-1 staffing for our patients with an Impella 2.5 until they are hemodynamically stable. A tubing system called the Quick Set-Up has been developed for use in the catheterization laboratory. The catheter depth is defined as the distance from the aortic annulus to the ventricular end of the cannula (Figure 4). One community hospitals approach to establishing a multidisciplinary program for use of the Impella 2.5 is described. Some patients on Impella support may be intubated and receiving mechanical ventilation. 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 2.5 catheter has 2 lumens. The Impella catheter must be adequately positioned to provide optimal hemodynamic support while minimizing the risk of complications, including hemolysis, interference with the mitral apparatus, suction events, or provocation of ventricular arrhythmias. The Impella 2.5 catheter is placed percutaneously through the common femoral artery and advanced retrograde to the left ventricle over a guidewire. Search for Similar Articles After advancement, always remove any slack by slowly pulling back on the catheter until cannula movement is observed. 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. : Survey of anticoagulation practices with the, 3. It is useful in patients undergoing high-risk PCIs. The recommended maximum performance level for continuous use is P8. Suction events may be caused by inadequate LV filling or incorrect Impella positioning with inlet area obstruction by a cardiac structure. Abiomed has sponsored several of these trials, including PROTECT I, PROTECT II, RECOVER I, RECOVER II, and ISAR-SHOCK. 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. For rapid weaning, the performance level is decreased by 1 or 2 levels every 5 to 15 minutes until the pump is set at P2. If the patient tolerates this slow weaning by remaining hemodynamically stable while at P2, the device is then removed. Unloading using Impella CP during profound cardiogenic - SpringerOpen The motor current will be flattened. 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. What Does A Swollen Uvula Mean | Buoy - Buoy Health Your message has been successfully sent to your colleague. 2017 Nov;45(11):1922-1929. doi: 10.1097/CCM.0000000000002676. If you have a swollen uvula, you may also be experiencing a sore throat, trouble swallowing, and maybe even a fever. 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. Esposito ML, Morine KJ, Annamalai SK, et al. The purpose of the bend is to orient the catheter toward the apical anteroseptal portion of the LV and away from the posterolateral wall, papillary muscles, and mitral apparatus. ). eCollection 2020 Jan. Barrionuevo-Snchez MI, Ariza-Sol A, Ortiz-Berbel D, Gonzlez-Costello J, Gmez-Hospital JA, Lorente V, Alegre O, Lla I, Snchez-Salado JC, Gmez-Lara J, Blasco-Lucas A, Comin-Colet J. J Geriatr Cardiol. Cardiogenic shock was defined as a (1) systolic blood pressure 90 mm Hg or need for inotropes or vasopressors to maintain systolic blood pressures 90 mm Hg, (2) signs of peripheral hypoperfusion, and (3) cardiac index <2.2 L/min/m 2 and pulmonary capillary wedge pressure 15 mm Hg. Abiomed also provides assistance with troubleshooting via 24-hour-a-day, 7-day-a-week telephone support. This arrangement allowed ample time for setting up the console and infusion pump before the Impella was placed. 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. 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. The patient was rapidly weaned from the Impella, which was removed in the catheterization laboratory. To monitor the severity of hemolysis we recommend daily monitoring of serum creatinine, and plasma-free hemoglobin (PFH) or lactate dehydrogenase (LDH). The .gov means its official. 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. FACT SHEET FOR HEALTHCARE PROVIDERS - Food and Drug Administration 3. placement monitoring is suspended or disabled. Fluoroscopic guidance in the catheterization laboratory or operating room is required. An audible alarm also will sound. 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.). 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. 6, 7 However, the device may migrate out of . Curr Cardiol Rep. 2018 Jan 19;20(1):2. doi: 10.1007/s11886-018-0946-2. She had a history of hypertension complicated by end-stage renal disease and was receiving dialysis treatments 3 times per week. The Impella RP is a right ventricular (RV) support system that is percutaneously positioned in the pulmonary artery via the femoral vein under fluoroscopy. Infusion of purge solution alone infrequently results in the desired therapeutic systemic anticoagulation and an additional infusion of parenteral heparin is often required. At follow-up 12 months later, the patient remained symptom-free with a normal ejection fraction of 55%. PMC If the patient tolerates the PCI procedure and hemodynamic instability does not develop, the Impella 2.5 may be removed at the end of the case while the patient is still in the catheterization laboratory. 2022 Feb 28;19(2):115-124. doi: 10.11909/j.issn.1671-5411.2022.02.003. Cardiogenic shock; Impella; Mechanical support devices; intra-aortic balloon pump; mechanical circulatory support; percutaneous ventricular assist device. On the placement signal screen, the waveform will show a ventricular, rather than an aortic, pressure waveform. Crowley J, Cronin B, Essandoh M, DAlessandro D, Shelton K, Dalia AA: Transesophageal echocardiography for, 2. Even a common cold can cause your uvula to swell. 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. The total duration of Impella support was slightly less than 2 hours. The optimal depth for the Impella 2.5, CP, 5.0, and LD is 3 cm to the beginning of the inlet area, and readjustment should be considered if the depth is more than 0.5 cm from this target. An official website of the United States government. Shearing of red blood cells is a common and clinically relevant problem with the Impella catheter. The Impella 2.5 device is a blood pump that is placed into your heart through a peripheral artery that will support your circulatory system during your elective or urgent high risk PCI (HRPCI). 8600 Rockville Pike The patients remaining hospital course was uneventful and he was discharged 2 days later taking appropriate medications for after PCI and to treat heart failure. Use of the Impella 2.5 in High-Risk - Critical Care Nursing Retract the device until diastolic pressures normalizes. Function keys that are used with the Impella 2.5 include the P-PERF, MENU, SIGNAL, SCALE, and the ON keys. echocardiography (right). Our training for staff from the catheterization laboratory consisted of a 3-hour session with didactic and hands-on training. Hear the stories of patients and explore the latest innovations in Impella technology. If TTE imaging is difficult, fluoroscopy or TEE can also be used. Image courtesy Sutter Medical Center, Sacramento, California. Please try again soon. Keywords: He had a long history of diabetes and had undergone coronary artery bypass surgery 20 years prior. Rao P, Khalpey Z, Smith R, Burkhoff D, Kociol RD: Venoarterial extracorporeal membrane oxygenation for, 7. The trials primary end point of hemodynamic improvement was defined as improved cardiac index at 30 minutes after implantation. 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). 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. Heparin 9000 units was administered intravenously for anticoagulation, and the Impella 2.5 was advanced into position in the left femoral artery. While the inability to provide anticoagulation is a contraindication, there is ongoing research into nonanticoagulant purge solution alternatives. Salmonella is a bacteria that can cause salmonellosis (non-typhoidal Salmonella enteritis), a common foodborne infection that causes watery diarrhea, fever, and abdominal cramps. The device may cause calcium to break off of the aortic valve and embolize, causing stroke. 0000005740 00000 n You may be trying to access this site from a secured browser on the server. Pahuja M, Hernandez-Montfort J, Whitehead EH, Kawabori M, Kapur NK. The Impella console powers the microaxial blood pump and monitors the functioning of the device, including the purge pressure and several other parameters. Advanced Percutaneous Mechanical Circulatory Support Devices for Cardiogenic Shock. The physician can evaluate left ventricular size and function and can quickly assess how well the patient tolerates decreases in the performance level. 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). 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. The Impella TM is a percutaneous, microaxial pump that continuously draws blood from its inlet inside the ventricle and expels it in the ascending aorta (Central Illustration) (12-15).Owing its properties, the Impella TM unloads the left ventricle (LV) while simultaneously augmenting cardiac output (CO). Following this trial, the Impella 2.5 device received its 510(k) approval from the Food and Drug Administration. (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.) We have extensive experience with the IABP and with surgically placed VADs, including the Abiomed AB5000, Thoratec CentriMag, XVE, and HeartMate II. Int J Heart Fail. Just visit www.ccnonline.org and click Respond to This Article in either the full-text or PDF view of the article. The MedStar Washington Hospital Center institutional review board approved the electronic medical record extraction and publication of this data. Two patients had transient hemolysis that was not clinically significant. Cardiogenic shock (CS) is a life-threatening condition associated with significant morbidity and mortality. The PCI procedure of the LAD SVG was then started. A culprit oriented approach should be used when troubleshooting the Impella supported patient with signs of persistent circulatory failure. When the heart displays a question mark over it with the words "Impella Position Wrong": 1. controller can't determine catheter position. At the end of the procedure, she was symptom free, and she was rapidly weaned from the Impella and the device was removed. Catheters with SmartAssist, however, will more specifically identify the nature of the mispositioning and can distinguish between the ventricular and aortic placement of the inlet and outlet areas (Figure 3C and 3D). When the patient is coming off of cardiopulmonary bypass, the performance level of the Impella pump, if the pump remains in place, must be increased to provide adequate flow to the patient. PDF PART 9 IMPELLA TROUBLESHOOTING AND RESUSCITATION - European Society of
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