The most common include suction, low purge pressure, and high purge pressure alarms. Data is temporarily unavailable. b)x""o0``k1h^xyW However, in severe cases of RV failure or when pre-capillary pulmonary hypertension is a contributing factor, right-sided MCS and pulmonary vasodilator titration may be required, respectively. When the Quick Set-Up is used, the 10% to 20% dextrose solution used to purge the motor is not heparinized. Percutaneous mechanical support devices are placed in a minimally invasive manner and provide life-saving assistance. The total duration of Impella support was slightly less than 2 hours. : Anticoagulation of, 4. E-mail: [emailprotected]; Twitter: @AlexPapolos. Potential complications include bleeding, limb ischemia, hemolysis, and infection. The Impella TM Device. 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. The Impella 2.5 catheter (Figure 2) contains a nonpulsatile microaxial continuous flow blood pump (Figure 3) that pulls blood from the left ventricle to the ascending aorta, creating increased forward flow and increased cardiac output. 2021 Feb;19(2):151-164. doi: 10.1080/14779072.2021.1863147. 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. 4, 5 Right ventricular failure occurs in 25% of patients after left ventricular assist device insertion, thus the advent of Impella RP. BX ct6J*0-ni0i6,,&%5y *P 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. There are two indications for anticoagulation when using the Impella catheter. 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. The left main lesion was crossed, and one stent was deployed at the lesion. Optimizing the spatial relationship between the catheter and adjacent intracardiac structures is necessary to minimize device-related complications. National Center for Biotechnology Information Expert commentary: The cannula appears as two bright echogenic, parallel lines, sometimes referred to as the railroad tracks, which ends at the inlet area. 2020 Jul;8(13):835. doi: 10.21037/atm.2020.03.152. After advancement, always remove any slack by slowly pulling back on the catheter until cannula movement is observed. Several parameters require regular monitoring for the duration of therapy. The device may cause calcium to break off of the aortic valve and embolize, causing stroke. 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. : Complete hemodynamic profiling with pulmonary artery catheters in, 6. You may be trying to access this site from a secured browser on the server. The use of continuous cardiac output monitoring may be useful for patients with cardiogenic shock. The patient was brought to the catheterization laboratory and prepared for the procedure. 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. 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). He was discharged home 2 days later. She was evaluated by our cardiac surgery team, who thought that she was a very high-risk candidate for surgery based on the recent fibrinolytic therapy, her renal failure, and the remote history of stroke. Ten different performance levels ranging from P0 to P9 are available (Table 5). The PCI procedure of the LAD SVG was then started. 2). More blood products were administered to patients treated with the Impella. 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. We have also placed the Impella 5.0 in 3 patients. Subramaniam AV, Barsness GW, Vallabhajosyula S, Vallabhajosyula S: Complications of temporary percutaneous. Once perfusion goals are met and proven to be stable at power level P2, the Impella catheter should be removed. One patient died before implantation of a device. Impella Positioning. 1. Normal Impella position in Parasternal Long This site needs JavaScript to work properly. 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). Quick Reference and Troubleshooting Guide Impella Heart IABP therapy has been in use since the late 1960s and has been widely used in clinical practice since that time. Refractory Impella Suction Alarms in the Setting of Extracorporeal 0000007230 00000 n Patel SM, Lipinski J, Al-Kindi SG, et al. If a significant color Doppler signal is observed below the valve (in the absence of significant aortic regurgitation), the device is likely too deep. The power connections for the pump motor and sensors are . The most common causes of Impella suction alarms include: malposition of the Impella, hypovolemia, RV failure, and pericardial tamponade. The 13F arterial sheath was sutured in placed for removal 4 hours later after the patient was returned to the CICU. Because the patient was tolerating the procedure well after this, the physician decided to stent the second diseased SVG. In our facility, physicians who can place this device are those who have interventional cardiology and/or cardiac surgery privileges. (Figure 3F). Brenda McCulloch is a member of the Abiomed Administrative Advisory Board. The console can run on a fully charged battery for up to 1 hour. : Survey of anticoagulation practices with the, 3. The patient with an Impella 2.5 is at risk of limb ischemia because of the large size of the device. Shearing of red blood cells is a common and clinically relevant problem with the Impella catheter. 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. 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. Accessibility 0000003312 00000 n Crit Care Nurse 1 February 2011; 31 (1): e1e16. Work with pharmacy and nursing staff to develop a standardized time for fluid and tubing changes. With the physician at the bedside, transthoracic echocardiography is performed and the pumps performance level is decreased. Keywords: Despite these changes, her blood pressure and cardiac rhythm remained stable. Serum level of lactate was lower in patients treated with the Impella. 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. Impella heart pumps (Abiomed) are intravascular microaxial blood pumps that provide temporary MCS during HRPCI or in the treatment of cardiogenic shock. Transthoracic echocardiography showed increased contractility, and the ejection fraction was 40%. It is not uncommon that some patients with severe cardiac dysfunction do not readily demonstrate the ability to wean from the Impella. 2021 Mar 26;100(12):e25159. Abiomed Impella RP Information for Use - Food and Drug Administration The sheath can then be removed later when the patients activated clotting time or partial thromboplastin time has returned to near normal levels. 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. He returned to the catheterization laboratory the next day for coronary intervention. The Impella 2.5 catheter shaft size is 9F and is 12F at its largest point, which is the microaxial blood pump. 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. The necessary images may be particularly difficult to obtain if the Impella device is medially or laterally oriented. Hemolysis can be mechanically induced when red blood cells are damaged as they pass through the microaxial pump. The purpose of this review is to comprehensively describe our strategy for managing, repositioning, and weaning the Impella catheter. 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). She had a history of hypertension complicated by end-stage renal disease and was receiving dialysis treatments 3 times per week. During stent deployment, the patient had severe chest pain and showed ST-segment elevation in the anterior leads. 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). Unlike the IABP, the Impella does not require timing, nor is a trigger from an electrocardiographic rhythm or arterial pressure needed (Table 1). Assign a point person who can oversee and coordinate the program. 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 Impella 2.5 catheter has 2 lumens. We provide 1-to-1 staffing for our patients with an Impella 2.5 until they are hemodynamically stable. 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. Free shipping for many products! Context in source publication. The aortic valve symbols will not be seen on the placement monitoring diagram. 2022 Feb 28;19(2):115-124. doi: 10.11909/j.issn.1671-5411.2022.02.003. 2020 Jan 22;2(1):23-44. doi: 10.36628/ijhf.2019.0015. Partner with industry. The proximal port of this lumen is yellow. During this time, transient no-reflow developed. She was treated with fibrinolytic therapy but continued to have chest pain. Careers. 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. A patient experiencing continuous suction may show systolic LV numbers, shown in white, that are uncoupled from the aortic numbers shown in red. 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. 0000001324 00000 n 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. doi: 10.1371/journal.pone.0247667. After the device is properly positioned, it is activated and blood is rapidly withdrawn by the microaxial blood pump from the inlet valve in the left ventricle and moved to the aorta via the outlet area, which sits above the aortic valve in the aorta (Figure 8). Notably, catheter position is best assessed ultrasonographically, as radiography does not accurately identify the cannula position relative to cardiac anatomic structures. Brenda McCulloch; Use of the Impella 2.5 in High-Risk Percutaneous Coronary Intervention. On arrival, his blood pressure was 151/88 mm Hg with a heart rate of 66/min. Xbao}*"&st V4qZz For this reason, we recommend a conservative approach to catheter manipulation with a the enemy of good is perfect philosophy. The patient was transferred to the CICU for continued monitoring. 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. Following this trial, the Impella 2.5 device received its 510(k) approval from the Food and Drug Administration. It is useful in patients undergoing high-risk PCIs. 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. Free shipping for many products! A 74-year-old man was transferred to our facility after sustaining a nonST-segment elevation myocardial infarction. 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. The cannula portion of the catheter is built with a 30 bend (except for the Impella LD, which has a straight design). Frontiers | Central Venous Pressure and Clinical Outcomes During Left If the patients ventricular function is very poor, a positioning alarm can occur. Garan AR, Kanwar M, Thayer KL, et al. 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. All patients with this device are observed by this clinical nurse specialist during their hospital stay. The Impella 2.5 instructions for use recommend a 40-minute manual hold to achieve hemostasis at the arterial access site. cardiac intensive care unit; cardiogenic shock; Impella; mechanical circulatory support. A 71-year-old man was referred to our facility for saphenous vein bypass graft (SVG), a high-risk PCI. 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. Find many great new & used options and get the best deals for Toddler On Board Car Sign, Suction Cup Baby On Board Sign, Child On Board Sign at the best online prices at eBay! POTENTIAL ADVERSE EVENTS Acute renal dysfunction, Aortic valve injury, Bleeding, Cardiogenic shock, Cerebral vascular accident/Stroke, Death, Hemolysis, Limb ischemia, Myocardial infarction, Renal failure, Thrombocytopenia and Vascular injury In addition to the risks above, there are other WARNINGS and PRECAUTIONS associated with Impella devices. 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 most commonly reported complications of Impella 2.5 placement and support include limb ischemia, vascular injury, and bleeding requiring blood transfusion.6,9 Hemolysis has been reported.5,10 Other potential complications include aortic valve damage, displacement of the distal tip of the device into the aorta, infection, and sepsis. Device failure, although not often reported, can occur. Impella has been proven to be safe and may be superior to other mechanical support devices in CS. 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. H\n0E The Impella console powers the microaxial blood pump and monitors the functioning of the device, including the purge pressure and several other parameters. Depending on the type of your infection . This should prompt urgent ultrasound assessment as the device may need to be either retracted or advanced. Patients with an Impella may go to the cardiovascular operating room for bypass surgery or valve repair/replacement. An audible alarm also will sound. 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. 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. The lesser used Impella LD is reserved for direct transaortic placement intraoperatively. Esposito ML, Morine KJ, Annamalai SK, et al. The Impella 2.5 can also be removed in the surgical setting with direct visualization of the common femoral artery. Image courtesy Sutter Medical Center, Sacramento, California. The device also cannot be used in patients with severe peripheral arterial disease because of the large sheath size required for its placement, nor can it be used in patients who cannot tolerate anticoagulation with heparin. The Impella is placed percutaneously, most commonly via the femoral or axillary artery, into the aorta, and across the aortic valve. One lumen carries fluid to the impellar blades and continuously purges the motor to prevent the formation of thrombus. Keyword Highlighting Impella Flashcards | Quizlet If you have a swollen uvula, you may also be experiencing a sore throat, trouble swallowing, and maybe even a fever. You may search for similar articles that contain these same keywords or you may On arrival, her blood pressure was 127/72 mm Hg, and her heart rate was 54/min. Impella ventricular support in clinical practice: Collaborative FOIA Troubleshooting Suspected Hemolysis in Patients Supported with Impella In some facilities, the perfusionist manages both the cardiopulmonary bypass and the Impella. Your message has been successfully sent to your colleague. Papolos, Alexander I. 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. 2022 Jan;19(1):1-10. doi: 10.1080/17434440.2022.2015323. Before The Impella is a really cool piece of equipment, a percutaneous ventricular assist device (primarily used for the LV, but can be used for the RV). Rao P, Khalpey Z, Smith R, Burkhoff D, Kociol RD: Venoarterial extracorporeal membrane oxygenation for, 7. The placement monitoring diagram will continuously scroll through 3 different images because it is not able to differentiate the position of the catheter. National Library of Medicine 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. The performance level determines the flow rate and the number of revolutions per minute. Cardiogenic shock (CS) is a life-threatening condition associated with significant morbidity and mortality. Pulmonary artery pressures remained elevated after this stent was placed, and the patient was given furosemide and nitroglycerin to decrease preload and increase diuresis. Percutaneous Mechanical Circulatory Support Devices for High-Risk Percutaneous Coronary Intervention. 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. Abiomed also provides assistance with troubleshooting via 24-hour-a-day, 7-day-a-week telephone support. There are currently five Impella catheters that provide left ventricular (LV) support (Figure 1). 2021 Feb 26;16(2):e0247667. Echocardiography for Evaluating Impella Catheter Position Following Read below to find out how long a swollen uvula lasts and how to get treatment. Weaning from the partial circulatory support provided by the Impella 2.5 can be approached in different ways. Staff received 1-to-1 mentoring from the Impella coordinator. We found it helpful for the first few Impella placements to be planned, elective placements for high-risk PCI. 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. Complications associated with mechanical circulatory support. One community hospitals approach to establishing a multidisciplinary program for use of the Impella 2.5 is described. The recommended maximum performance level for continuous use is P8. The Impella (Abiomed, Danvers, MA) mechanical circulatory support (MCS) system is a catheter-based continuous flow pump that is typically placed percutaneously or by surgical cutdown into the femoral or subclavian artery. Bivalirudin was administered for anticoagulation, and the Impella 2.5 was advanced into position in the left femoral artery. For more information, please refer to our Privacy Policy. The tip of the catheter has a flexible pigtail, intended to prevent mechanical injury of the ventricle (absent on the larger LD and 5.5 models). 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 patients diastolic pressure increased significantly more with Impella support than with IABP support (P=.002). 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. Our facility has a high-volume interventional cardiology program as well as a busy adult and pediatric cardiovascular surgery service. Toddler On Board Car Sign, Suction Cup Baby On Board Sign, Child - eBay 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). 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. Impella Flashcards | Quizlet Using the LV Waveform to Troubleshoot Suction Events - Heart Recovery 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. The motor current will be flattened. The partial thromboplastin time should be monitored every 4 to 8 hours and maintained at about 45 to 55 seconds, unless a higher partial thromboplastin time is required for some other reason. To date, we have placed an Impella 2.5 in about 40 patients. Patients who have had the device in longer or who were in unstable condition during the procedure may benefit from a slower weaning process. The catheter is then pulled back from the left ventricle into the ascending aorta and then completely withdrawn. The use of pulmonary artery catheters with ongoing RP has not been thoroughly evaluated, and evaluation should also rely on clinical evaluation, oxygen demand, chest X-ray, etc. Support with Impella versus intra-aortic balloon pump in acute myocardial infarction complicated by cardiogenic shock: A protocol for systematic review and meta-analysis. Troubleshooting tips. 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. Consider when SBP <90 mmHg sustained for >30 min (or vasopressors required) AND clinical or objective signs of tissue hypoperfusion (see below). 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 newer option that is now available for select patients is the Impella 2.5, a short-term partial circulatory support device or percutaneous ventricular assist device (VAD). The Impella device can be withdrawn, leaving the arterial sheath in place. 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. The catheter device was connected to the Impella console and support was initiated. Important contraindications to use of the Impella MCS system are the presence of: moderate to severe aortic regurgitation, mechanical aortic valve, aortic dissection, LV thrombus, or ventricular sepal defect. 6, 7 However, the device may migrate out of . The pharmacy prepares the heparinized 20% glucose purge solution and sends it to the unit before our standard change time of 3 pm daily. Methods Cardiogenic shock was induced by injecting microspheres in the left main coronary artery in 18 adult Danish Landrace pigs. The Rise of Endovascular Mechanical Circulatory Support Use for Cardiogenic Shock and High Risk Coronary Intervention: Considerations and Challenges. v67z]FcUe7sne[l}g&_}V^7vk~7S/o}AoepY5OTYe>acQ*|o? \-yVJUrM^2E~,d3EN9--u1C~A+ 0000006172 00000 n Unloading using Impella CP during profound cardiogenic - SpringerOpen In our facility, we often use transthoracic echocardiography to aid in the assessment of our patients. Information about the alarm can be seen on the console screen. Arterial repair is done at that time, and the incision is covered with a sterile dressing. Sheaths were placed in the right femoral vein, the right femoral artery, and the left femoral artery. Our training for staff from the catheterization laboratory consisted of a 3-hour session with didactic and hands-on training. Curr Cardiol Rep. 2018 Jan 19;20(1):2. doi: 10.1007/s11886-018-0946-2. Adequate blood flow was reestablished after the intracoronary administration of 500 g nitroglycerin. Expert Rev Med Devices. For more Impella resources, subscribe to our wee.
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