Device failure, although not often reported, can occur. 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. Percutaneous mechanical support devices are placed in a minimally invasive manner and provide life-saving assistance. Diastolic LV numbers are also very negative and the Max and Min flows displayed on the console are lower than expected. 597 0 obj <> endobj xref 2020 Jan 22;2(1):23-44. doi: 10.36628/ijhf.2019.0015. Adequate blood flow was reestablished after the intracoronary administration of 500 g nitroglycerin. When hemolysis occurs, hemoglobin level and hematocrit decrease, haptoglobin level decreases, and plasma levels of free hemoglobin increase. Hemolysis can occur in patients who are on the Impella 2.5. We found performing such changes at a consistent time to be very helpful. Unauthorized use of these marks is strictly prohibited. While a small amount of hemolysis is unavoidable, significant hemolysis can quickly cause pigment nephropathy and further complicate the management of an already critically ill patient. The coronary guidewire was advanced through the LIMA graft to the distal LAD. *; Barnett, Christopher F.; Tuli, Aakash; Vavilin, Ilan; Kenigsberg, Benjamin B. Retract the device until diastolic pressures normalizes. With the physician at the bedside, transthoracic echocardiography is performed and the pumps performance level is decreased. In our case, the Impella had already been confirmed to be in the appropriate position. Information about the alarm can be seen on the console screen. Some were designed to support future versions of Impella catheters. The device may cause calcium to break off of the aortic valve and embolize, causing stroke. 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. Hemolysis, as measured by the plasma level of free hemoglobin, was higher in patients treated with the Impella. IABP therapy has been in use since the late 1960s and has been widely used in clinical practice since that time. 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. b)x""o0``k1h^xyW Crit Care Nurse 1 February 2011; 31 (1): e1e16. Image courtesy ABIOMED Inc, Danvers, Massachusetts. government site. Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints@aacn.org. Consider when SBP <90 mmHg sustained for >30 min (or vasopressors required) AND clinical or objective signs of tissue hypoperfusion (see below). Bivalirudin was administered for anticoagulation, and the Impella 2.5 was advanced into position in the left femoral artery. The arterial sheath can be left in place to be removed separately, or the catheter and the sheath can be removed as a unit, as is common when removing an intra-aortic balloon catheter placed through a sheath. 2020 Jul;8(13):835. doi: 10.21037/atm.2020.03.152. 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. 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. 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. We found it helpful for the first few Impella placements to be planned, elective placements for high-risk PCI. This arrangement allows rapid initial setup of the console so that support can be initiated quickly. 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. 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. 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. Regular documentation is essential, and review of trends is useful when troubleshooting. Placement monitoring screen display shows that pump position is wrong. The placement monitoring diagram will show the aortic valve symbols distal to the pump (Figure 9). 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 is placed percutaneously, most commonly via the femoral or axillary artery, into the aorta, and across the aortic valve. Areas covered: Diagnostic cardiac catheterization and coronary angiography performed at the referring facility showed severe triple vessel coronary disease and high-grade lesions in 2 SVGs. 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. Fluoroscopic guidance in the catheterization laboratory or operating room is required. LV Aortic valve Mitral valve Impella 2.5 outlet area Impella 2.5 . A low purge pressure can allow blood to enter the motor and damage the motor, rendering the device inoperable. 2). National Library of Medicine Nalluri N, Patel N, Saouma S, Anugu VR, Anugula D, Asti D, Mehta V, Kumar V, Atti V, Edla S, Grewal RK, Khan HM, Kanotra R, Maniatis G, Kandov R, Lafferty JC, Dyal M, Alfonso CE, Cohen MG. Abiomed provides strong clinical support as well as excellent print and Web-based educational materials. The SVG was aspirated before a distal protection device was placed. Heparin 9000 units was administered intravenously for anticoagulation, and the Impella 2.5 was advanced into position in the left femoral artery. 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. (Figure 3F). echocardiography (right). Before 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. 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. The power connections for the pump motor and sensors are . 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. 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. 2017 Nov;45(11):1922-1929. doi: 10.1097/CCM.0000000000002676. Repositioning is best performed under fluoroscopic guidance, whenever possible. His left ventricular end-diastolic pressure was markedly elevated at 40 mm Hg (normal, 512 mm Hg), and his cardiac index was reduced at 1.98. The Impella 2.5 should not be used in patients with aortic valve disease or known left ventricular thrombus. It is used for high-risk percutaneous coronary intervention and CS. The MedStar Washington Hospital Center institutional review board approved the electronic medical record extraction and publication of this data. For this reason, we recommend a conservative approach to catheter manipulation with a the enemy of good is perfect philosophy. The left main lesion was crossed, and one stent was deployed at the lesion. Parameters to assess regularly include placement signal, placement monitoring (pump position), dual signal, purge pressure, motor current, and speed (Table 6). 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 . None of the patients had hemodynamic instability develop during the procedure. ?(x$2pD] 9A =9@w E" endstream endobj 612 0 obj <>/Filter/FlateDecode/Index[62 535]/Length 41/Size 597/Type/XRef/W[1 1 1]>>stream 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. 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 placement signal will show a normal appearing aortic waveform with systolic and diastolic pressures similar to those shown by the patients arterial catheter. At follow-up 12 months later, the patient remained symptom-free with a normal ejection fraction of 55%. 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 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. In these illustrations, the Impella Catheter is positioned correctly. A culprit oriented approach should be used when troubleshooting the Impella supported patient with signs of persistent circulatory failure. No reflow is a phenomenon in PCI that can cause severe hemodynamic compromise because myocardial perfusion through a given segment of the coronary circulation is inadequate, yet no angiographic evidence of mechanical obstruction of the vessel is apparent.15 The patients pulmonary artery pressures increased to 93/4058 mm Hg and the cardiac index decreased to 2.2. In our facility, we have a trained CICU nurse managing the Impella while the patient is in the cardiovascular operating room. The catheter is then pulled back from the left ventricle into the ascending aorta and then completely withdrawn. Complications associated with mechanical circulatory support. The question that then arises is when to favor escalating inotropes to assist in device weaning. 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. 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. 1. An official website of the United States government. Improvements in cardiac index were significantly greater in the patients with the Impella than in patients with the IABP (P=.02). Shearing of red blood cells is a common and clinically relevant problem with the Impella catheter. A tubing system called the Quick Set-Up has been developed for use in the catheterization laboratory. 0000004020 00000 n Cardiogenic shock - Impella 2.5, CP, 5.0, LD - Temporary VAD for less than or equal to 4 days: 2.5, CP - Temporary VAD for less than or equal to 14 dyas: 5.0, LD Infusion of purge solution alone infrequently results in the desired therapeutic systemic anticoagulation and an additional infusion of parenteral heparin is often required. 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). The Impella 2.5 catheter shaft size is 9F and is 12F at its largest point, which is the microaxial blood pump. Cardiogenic shock (CS) is a life-threatening condition associated with significant morbidity and mortality. 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. Epub 2020 Dec 28. Weaning from the partial circulatory support provided by the Impella 2.5 can be approached in different ways. Some patients on Impella support may be intubated and receiving mechanical ventilation. During this time, transient no-reflow developed. Our typical hemodynamic targets are a mean arterial pressure of 6070 mm Hg, a right atrial pressure of 812 mm Hg, a pulmonary arterial wedge pressure <15 mm Hg, and a cardiac index >2.0 L/min/m2. The site is secure. 0000003906 00000 n 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. 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. Data is temporarily unavailable. It is useful in patients undergoing high-risk PCIs. The optimal cannula depth of the Impella 5.5 is 4.5 cm +/- 0.5 cm to the beginning of the inlet area, as this model has a longer cannula. The purpose of this review is to describe how to manage, reposition, and wean patients from the Impella catheter. HHS Vulnerability Disclosure, Help 29. 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. Ongoing practice is essential to develop and maintain competency. Work with pharmacy and nursing staff to develop a standardized time for fluid and tubing changes. Additionally, cardiac resuscitation can cause device migration and as such, post-arrest ultrasound confirmation of position is recommended. H\n0E We have 2 nurses at the bedside for the tubing change. 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. On arrival, her blood pressure was 127/72 mm Hg, and her heart rate was 54/min. 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. 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. The console uses this pressure measurement to calculate the catheters position. doi: 10.1097/MD.0000000000025159. Patients with an Impella may go to the cardiovascular operating room for bypass surgery or valve repair/replacement. 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. Careers. One patient died before implantation of a device. To date, we have placed an Impella 2.5 in about 40 patients. : Simultaneous venoarterial extracorporeal membrane oxygenation and percutaneous left ventricular decompression therapy with, 8. Catheters with SmartAssist have an upgraded optical pressure sensor that directly measures aortic pressure and uses changes in motor current to infer an estimated LV pressure waveform. P2 is the lowest performance level that can be used while the distal end of the Impella 2.5 is in the left ventricle. We have gained much knowledge since implementing our Impella program in April 2008. The use of continuous cardiac output monitoring may be useful for patients with cardiogenic shock. 0000000016 00000 n The Suction alarm is triggered when sudden decreases in the placement signal pressure occur in association with lower than expected flows. 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. If Impella malposition is suspected, use echo to look for inlet or outlet obstructions. The Impella coordinator is present for implants to assist the catheterization laboratory staff as needed. Include the cardiovascular surgery staff and perfusion staff in the initial training. Percutaneous Mechanical Circulatory Support Devices for High-Risk Percutaneous Coronary Intervention. The Impella MCS system is a relatively new technology that has become widely used for the treatment of cardiogenic shock in medical and surgical cardiac intensive care units. : Survey of anticoagulation practices with the, 3. 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. Keyword Highlighting 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. a1 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. The patient was brought to the catheterization laboratory and prepared for the procedure. In our facility, physicians who can place this device are those who have interventional cardiology and/or cardiac surgery privileges. 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. Highlight selected keywords in the article text. 2. position is wrong. 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. 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. Clipboard, Search History, and several other advanced features are temporarily unavailable. When activated, the console is silent. Our training for staff from the catheterization laboratory consisted of a 3-hour session with didactic and hands-on training. Despite these changes, her blood pressure and cardiac rhythm remained stable. The catheter depth is defined as the distance from the aortic annulus to the ventricular end of the cannula (Figure 4). 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). Reed BN, DiDomenico RJ, Allender JE, et al. She was treated with fibrinolytic therapy but continued to have chest pain. 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). 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. 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. An additional method to ensure proper depth is to interrogate the aortic root with color Doppler from the parasternal long-axis view. 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. Frequent hemodynamic evaluation is needed. Keywords: We have also placed the Impella 5.0 in 3 patients. Suction events may be caused by inadequate LV filling or incorrect Impella positioning with inlet area obstruction by a cardiac structure. Identification of Cardiogenic Shock This site needs JavaScript to work properly. 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). Conversely, lack of expected pulsatility in the placement signal and/or in the motor current signal may reflect a problem. Optimizing the spatial relationship between the catheter and adjacent intracardiac structures is necessary to minimize device-related complications. The catheter device was connected to the Impella console and support was initiated. Image courtesy Sutter Medical Center, Sacramento, California.
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