On imaging, if the LV appears overly decompressed due to a significant interventricular septal shift, then reducing the Impella speed, escalating inotropy to support the RV, and increasing volume removal is commonly the best course of action. He declined repeat bypass surgery. Patel SM, Lipinski J, Al-Kindi SG, et al. 2017 Nov;45(11):1922-1929. doi: 10.1097/CCM.0000000000002676. In our facility, we often use transthoracic echocardiography to aid in the assessment of our patients. One lumen carries fluid to the impellar blades and continuously purges the motor to prevent the formation of thrombus. There is a pressure sensor built into the aortic end of the cannula that is used to produce a placement signal waveform tracing (Figure 3A). An audible alarm also will sound. Serum level of lactate was lower in patients treated with the Impella. She was treated with fibrinolytic therapy but continued to have chest pain. Areas covered: 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. Improvements in cardiac index were significantly greater in the patients with the Impella than in patients with the IABP (P=.02). He had a long history of diabetes and had undergone coronary artery bypass surgery 20 years prior. The Impella RP is a right ventricular (RV) support system that is percutaneously positioned in the pulmonary artery via the femoral vein under fluoroscopy. Careers. 2). Hear the stories of patients and explore the latest innovations in Impella technology. The patients hemodynamic status is assessed after every decrease in performance level. With correct positioning and function, the placement signal and motor current are pulsatile, reflecting the dynamic pressure gradient between the aorta and LV, as well as the cyclical variation in energy required to maintain the desired motor speed over the cardiac cycle (Figure 3A). We provide 1-to-1 staffing for our patients with an Impella 2.5 until they are hemodynamically stable. The placement signal will show a normal appearing aortic waveform with systolic and diastolic pressures similar to those shown by the patients arterial catheter. 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. Like all LV assist devices, the Impella can only pump as much blood as is available to it. Purge Screen Displays purge system information displayed as a function of time. 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. 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. 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. 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. 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. 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. 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. Crit Care Nurse 1 February 2011; 31 (1): e1e16. 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. Patients who have had the device in longer or who were in unstable condition during the procedure may benefit from a slower weaning process. 8600 Rockville Pike 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. 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. Papolos, Alexander I. Hemolysis, as measured by the plasma level of free hemoglobin, was higher in patients treated with the Impella. 0000014939 00000 n IABP therapy has been in use since the late 1960s and has been widely used in clinical practice since that time. Free shipping for many products! We follow our hospitals protocol for achieving hemostasis, using either manual or mechanical compression. At P8, the flow rate is 1.9 to 2.6 L/min and the motor is turning at 50000 revolutions per minute. 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. Advanced Percutaneous Mechanical Circulatory Support Devices for Cardiogenic Shock. SmartAssist technology on the Impella CP or Impella 5.5 devices can help with this as well. 0000004641 00000 n Further to this point, cases of Impella weaning intolerance or clinical decompensation after explantation beg the complicated question of when to consider escalating inotropes and/or pursuing additional MCS as bridge-to-recovery or bridge-to-LVAD/transplant versus palliation, and must be determined on an individual basis. Coordination with the perfusionist is essential when patients are being placed on cardiopulmonary bypass. He had severe mitral regurgitation. A 71-year-old man was referred to our facility for saphenous vein bypass graft (SVG), a high-risk PCI. The Impella 2.5 catheter has 2 lumens. 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. government site. The use of continuous cardiac output monitoring may be useful for patients with cardiogenic shock. The Impella mechanical circulatory support (MCS) system is a catheter-based continuous flow cardiac assist device that is widely used in the treatment of cardiogenic shock in medical and surgical cardiac intensive care units. 29. The Impella 2.5 is a percutaneously placed partial circulatory assist device that is increasingly being used in high-risk coronary interventional procedures to provide hemodynamic support. The Impella 2.5 should not be used in patients with aortic valve disease or known left ventricular thrombus. hbb2d`b``3 1x(@ % endstream endobj 598 0 obj <>/Metadata 60 0 R/PageLabels 55 0 R/PageLayout/TwoColumnRight/Pages 57 0 R/StructTreeRoot 62 0 R/Type/Catalog/ViewerPreferences<>>> endobj 599 0 obj >/PageTransformationMatrixList<0[1.0 0.0 0.0 1.0 0.0 -297.638]>>/PageUIDList<0 21587>>/PageWidthList<0 419.528>>>>>>/Resources<>/Font<>/ProcSet[/PDF/Text]/XObject<>>>/Rotate 0/StructParents 0/TrimBox[0.0 0.0 419.528 595.276]/Type/Page>> endobj 600 0 obj <> endobj 601 0 obj <> endobj 602 0 obj <> endobj 603 0 obj <> endobj 604 0 obj <>stream 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. Several parameters require regular monitoring for the duration of therapy. As soon as the signal has been established, Impella support is immediately restarted. Slow weaning is accomplished by decreasing the performance level by 1 or 2 levels every 2 or 3 hours. 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. (Figure 3F). While the inability to provide anticoagulation is a contraindication, there is ongoing research into nonanticoagulant purge solution alternatives. Identification of Cardiogenic Shock Just visit www.ccnonline.org and click Respond to This Article in either the full-text or PDF view of the article. When activated, the console is silent. 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. Train a core group of critical care nurses to care for the patient, monitor the device, change tubings, and troubleshoot alarms. Note: consider the diagnosis of normotensive cardiogenic shock when normal BP but rising lactate and transaminitis. There are two indications for anticoagulation when using the Impella catheter. 6, 7 However, the device may migrate out of . : Complete hemodynamic profiling with pulmonary artery catheters in, 6. Keyword Highlighting A console simulator is available that can be used to practice troubleshooting. Jo Kajewski, Advanced Impella Trainer, gives an in-depth look at managing Impella positioning using imaging. Expert Rev Cardiovasc Ther. We found it helpful for the first few Impella placements to be planned, elective placements for high-risk PCI. We have 2 nurses at the bedside for the tubing change. Crowley J, Cronin B, Essandoh M, DAlessandro D, Shelton K, Dalia AA: Transesophageal echocardiography for, 2. 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. MeSH Impella heart pumps (Abiomed) are intravascular microaxial blood pumps that provide temporary MCS during HRPCI or in the treatment of cardiogenic shock. doi: 10.1371/journal.pone.0247667. 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. None of the patients had hemodynamic instability develop during the procedure. Crit Care Med. Some error has occurred while processing your request. Assign a point person who can oversee and coordinate the program. The ISAR-SHOCK trial was done to evaluate the safety and efficacy of the Impella 2.5 versus the IAPB in patients with cardiogenic shock due to acute myocardial infarction.5 Patients were randomized to support from an IABP (n=13) or an Impella (n=12). If the catheter pigtail is hooked on the mitral apparatus and/or papillary muscle, it may be necessary to first advance the catheter deeper into the ventricle and then rotate the catheter to disengage it from the valvular structures. Intravascular ultrasound was performed to confirm optimal stent placement. The .gov means its official. Distal pulses of the affected leg should be assessed at least hourly. He had a history of coronary artery bypass grafting surgery several years prior as well as heart failure. One patient died before implantation of a device. The use of inotropic agents and vasopressors was similar in both groups of patients. Automated Impella Controller (collectively, "Impella System Therapy"), are temporary ventricular support devices intended for short term use ( 4 days for the P2 is the lowest performance level that can be used while the distal end of the Impella 2.5 is in the left ventricle. Immediately before removal of the device, decrease the performance level to P0. 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. 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. Potential complications include bleeding, vascular injury, hemolysis, infection, sepsis, and device malfunction or failure. Catheter position should be assessed daily and in response to unexpected clinical changes or specific device alarms. 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. Ten different performance levels ranging from P0 to P9 are available (Table 5). 597 0 obj <> endobj xref Rotation can often be difficult and applying more than a full 360 degrees of torque is often necessary. All cases are also followed by the cardiac surgeon who oversees our VAD program and a critical care intensivist. As the performance level increases, the flow rate and number of revolutions per minute increase. Review of patient care management strategies, console troubleshooting, and fluid/tubing setup has also been added to our annual VAD skills fair (Table 9). The coronary guidewire was advanced through the LIMA graft to the distal LAD. echocardiography (right). Adequate blood flow was reestablished after the intracoronary administration of 500 g nitroglycerin. As with all forms of MCS, device-related complications remain a major concern, the incidence of which can be mitigated by adhering to a few fundamental concepts in device management. The patients diastolic pressure increased significantly more with Impella support than with IABP support (P=.002). The total duration of Impella support was slightly less than 2 hours. A tubing system called the Quick Set-Up has been developed for use in the catheterization laboratory. Our training for our cardiac intensive care unit (CICU) nurses consisted of a series of three 1-hour sessions, encompassing a review of pertinent physiology and hemodynamics, Impella console management and troubleshooting, and tubing changes with hands-on practice and documentation practice. You may search for similar articles that contain these same keywords or you may a1 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. Cardiogenic shock; Impella; Mechanical support devices; intra-aortic balloon pump; mechanical circulatory support; percutaneous ventricular assist device. 0000001527 00000 n 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. Submitted for consideration June 2021; accepted for publication in revised form December 2021. Please enable scripts and reload this page. At the end of rapid weaning, the Impella device can then be removed as described in the next section. : Survey of anticoagulation practices with the, 3. 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. 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. The motor current signal will be flattened. Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints@aacn.org. To date, we have placed an Impella 2.5 in about 40 patients. He was discharged home 2 days later. 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. For patients who become hemodynamically unstable or who have complications during the PCI (eg, no reflow, hypotension, or lethal arrhythmias), the device can remain in place for continued partial circulatory support, and the patient is transported to the critical care setting. In our facility, we have a trained CICU nurse managing the Impella while the patient is in the cardiovascular operating room. Shearing of red blood cells is a common and clinically relevant problem with the Impella catheter. His estimated ejection fraction was markedly decreased at 20% (normal, 55%70%) on a recent echocardiogram. When hemolysis occurs, hemoglobin level and hematocrit decrease, haptoglobin level decreases, and plasma levels of free hemoglobin increase. Hemolysis can be mechanically induced when red blood cells are damaged as they pass through the microaxial pump. Our use of the Impella 2.5 was our first experience with percutaneously placed partial circulatory support devices. 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. Expert Rev Med Devices. 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). H\n0E Int J Heart Fail. The proximal port of this lumen is yellow. Expert commentary: The motor current will be flattened. : Increased plasma-free hemoglobin levels identify hemolysis in patients with, 5. Because the patient was tolerating the procedure well after this, the physician decided to stent the second diseased SVG. A low purge pressure alarm indicates that the purge pressure to the Impella motor has decreased below 300 mm Hg. 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. Pahuja M, Hernandez-Montfort J, Whitehead EH, Kawabori M, Kapur NK. Components of the Impella 2.5 cardiac assist device. The patient was brought to the catheterization laboratory and prepared for the procedure. Indications 1. 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). 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. The proximal port of this lumen is red. The Impella coordinator is present to assist with tubing changes as needed by the nursing staff. 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). SyBbhD&,V}R#Ohov]F}9v_c- 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. Clipboard, Search History, and several other advanced features are temporarily unavailable. Potential complications include bleeding, limb ischemia, hemolysis, and infection. Please try after some time. Abiomed provides strong clinical support as well as excellent print and Web-based educational materials. 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. After advancement, always remove any slack by slowly pulling back on the catheter until cannula movement is observed. 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. In cases of RV failure, Impella flows can be limited by poor RV output as well as by RV distention that shifts the interventricular septum toward the LV, which can precipitate suction events. Weaning from the partial circulatory support provided by the Impella 2.5 can be approached in different ways. 0000006172 00000 n BX ct6J*0-ni0i6,,&%5y *P Partner with industry. Our practice of monitoring and managing RV function relies heavily on invasive hemodynamics and ultrasound imaging. It is used for high-risk percutaneous coronary intervention and CS. The left main lesion was crossed, and one stent was deployed at the lesion. Two patients had transient hemolysis that was not clinically significant. 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.
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