Our facility has a high-volume interventional cardiology program as well as a busy adult and pediatric cardiovascular surgery service. 597 17 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. 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). (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.) When hemolysis occurs, hemoglobin level and hematocrit decrease, haptoglobin level decreases, and plasma levels of free hemoglobin increase. At maximum performance (P9), the pump rotates at 50000 revolutions per minute and delivers a flow rate of 2.1 to 2.6 L/min. 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. Frequent hemodynamic evaluation is needed. a1 Consider when SBP <90 mmHg sustained for >30 min (or vasopressors required) AND clinical or objective signs of tissue hypoperfusion (see below). The 13F arterial sheath was sutured in placed for removal 2 hours later, after the patient had returned to the CICU. You may search for similar articles that contain these same keywords or you may During this time, transient no-reflow developed. The patients vital signs and cardiac rhythm remained stable throughout the procedure. Hemolysis can occur in patients who are on the Impella 2.5. Some error has occurred while processing your request. Impella Devices 101 - REBEL EM - Emergency Medicine Blog 0000014939 00000 n 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 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. Despite these changes, her blood pressure and cardiac rhythm remained stable. If the catheter is completely out of the ventricle, it should be repositioned across the valve over a guidewire. Additional torque can be achieved by rotating the red Impella plug (Figure 5) at the proximal end of the catheter in the desired direction. 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. If the hemolysis is severe, hemoglobinuria will be seen; if the hemolysis is sustained, acute kidney injury will occur. A multidisciplinary approach to establishing a program for the Impella is useful in ensuring competency and good outcomes for patients. Accurate Impella placement is essential during all phases of Impella support but it is particularly important for long term support. Disclosure: The authors have no funding or conflicts of interest to report. 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 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. 0000007230 00000 n Detailed view of distal end of Impella 2.5. Ongoing practice is essential to develop and maintain competency. The MedStar Washington Hospital Center institutional review board approved the electronic medical record extraction and publication of this data. Rolling cart carrying components required to run the Impella 2.5. An enlarged uvula is often caused by infection, an allergic reaction, or irritation from chemicals or medical procedures. Brenda McCulloch; Use of the Impella 2.5 in High-Risk Percutaneous Coronary Intervention. Quick Reference and Troubleshooting Guide The VAD coordinators also provide valuable assistance. A fluid challenge test can be useful in difficult cases. Retract the device until diastolic pressures normalizes. 2020 Jan 22;2(1):23-44. doi: 10.36628/ijhf.2019.0015. 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. 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. 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. This arrangement allows rapid initial setup of the console so that support can be initiated quickly. The 13F arterial sheath was sutured in placed for removal 4 hours later after the patient was returned to the CICU. 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. Include the cardiovascular surgery staff and perfusion staff in the initial training. Regular documentation is essential, and review of trends is useful when troubleshooting. 2021 Feb 26;16(2):e0247667. Train a core group of nurses and cardiovascular technologists from the catheterization laboratory for initial setup of the console, catheter preparation, and assisting with placement of the device. 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. Search for other works by this author on: Percutaneous left ventricular support devices, A randomized clinical trial to evaluate the safety and efficacy of a percutaneous left ventricular assist device versus intra-aortic balloon pumping for treatment of cardiogenic shock caused by myocardial infarction, Effects of left ventricular unloading by Impella Recover LP 2.5 on coronary hemodynamics, Nursing care of patients receiving intra-aortic balloon counterpulsation, Safety and feasibility of elective high-risk percutaneous coronary intervention procedures with left ventricular support of the Impella Recover LP 2.5, A prospective feasibility trial investigating the use of the Impella 2.5 system in patients undergoing high-risk percutaneous coronary intervention (the PROTECT I trial): Initial U.S. experience, Feasibility and long-term safety of elective Impella-assisted high-risk percutaneous coronary intervention: a pilot two-centre study, Use of Impella Recover LP 2.5 in elective high risk percutaneous coronary intervention [published online ahead of print September 2, 2009], Update on ventricular assist device technology, Impella: Instructions for Use for the Impella 2.5 Circulatory Support System, The coronary no-reflow phenomenon: a review of mechanisms and therapies, 2011 American Association of Critical-Care Nurses, This site uses cookies. Device failure, although not often reported, can occur. The Impella RP is a right ventricular (RV) support system that is percutaneously positioned in the pulmonary artery via the femoral vein under fluoroscopy. Inotropic agents, such as dobutamine and milrinone, and vasopressors, such as dopamine and norepinephrine, may still be needed after the Impella 2.5 is placed to maintain a cardiac index of at least 2 and systolic blood pressure at 90 mm Hg or higher. Szymanski TW, Weeks PA, Lee Y, et al. 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. Impella has been proven to be safe and may be superior to other mechanical support devices in CS. PDF Patient Information for the Impella 2 - Food and Drug Administration The SVG was aspirated before a distal protection device was placed. The placement monitoring diagram will show the aortic valve symbols distal to the pump (Figure 9). Three sequential stents were placed in the area of disease. The arterial access site must be assessed regularly for bleeding and development of a hematoma. Heparin 9000 units was administered intravenously for anticoagulation, and the Impella 2.5 was advanced into position in the left femoral artery. 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. LV Aortic valve Mitral valve Impella 2.5 outlet area Impella 2.5 . 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 Impella 2.5 should not be used in patients with aortic valve disease or known left ventricular thrombus. The Impella is placed percutaneously, most commonly via the femoral or axillary artery, into the aorta, and across the aortic valve. v67z]FcUe7sne[l}g&_}V^7vk~7S/o}AoepY5OTYe>acQ*|o? \-yVJUrM^2E~,d3EN9--u1C~A+ 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. Abiomed also provides assistance with troubleshooting via 24-hour-a-day, 7-day-a-week telephone support. She had no further chest pain during her hospitalization and was discharged home in stable condition 3 days later. Ann Transl Med. E-mail: [emailprotected]; Twitter: @AlexPapolos. The second lumen ends near the motor above the level of the aortic valve and is used to monitor aortic pressure. Patients must have some level of left ventricular function for an IABP to be effective. 0000003906 00000 n 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. 0000005131 00000 n Brenda McCulloch is a member of the Abiomed Administrative Advisory Board. A broad mosaic color Doppler pattern caused by artifact from the motor will be seen, which should be limited to the aortic side of the valve. The catheter device was connected to the Impella console and support was initiated. Frontiers | Ventricular Unloading Using the ImpellaTM Device in 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.). A cutdown is performed, and the device is removed by the surgeon. 0000003312 00000 n 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. 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. The use of anticoagulation is required, and bleeding may develop in some patients. government site. All patients with this device are observed by this clinical nurse specialist during their hospital stay. Disclaimer. High-risk PCI - Impella 2.5, CP - < 6 hours (temporary) VAD for use during high-risk percutaneous coronary intervention (prevent hemodynamic instability) 2. 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. The impellar blades of the motor could break up the thrombi, causing arterial embolization. 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. Optimizing the spatial relationship between the catheter and adjacent intracardiac structures is necessary to minimize device-related complications. The patient with an Impella 2.5 is at risk of limb ischemia because of the large size of the device. : Simultaneous venoarterial extracorporeal membrane oxygenation and percutaneous left ventricular decompression therapy with, 8. : Anticoagulation of, 4. 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. A 74-year-old man was transferred to our facility after sustaining a nonST-segment elevation myocardial infarction. It cannot be used in patients with documented left ventricular thrombus. This should prompt urgent ultrasound assessment as the device may need to be either retracted or advanced. 2017 Nov;45(11):1922-1929. doi: 10.1097/CCM.0000000000002676. Single Access Technique. The typical infusion rate for the purge fluid is 7 to 20 mL/h. Abiomed has sponsored several of these trials, including PROTECT I, PROTECT II, RECOVER I, RECOVER II, and ISAR-SHOCK. Arterial repair is done at that time, and the incision is covered with a sterile dressing. Frequently Asked Questions About Hemolysis | HeartRecovery.com Patients on Impella 2.5 support who may require interrogation of a permanent pacemaker or implantable cardioverter defibrillator present an interesting situation. At the end of rapid weaning, the Impella device can then be removed as described in the next section. doi: https://doi.org/10.4037/ccn2011293. On arrival, his blood pressure was 151/88 mm Hg with a heart rate of 66/min. Complications associated with mechanical circulatory support. Once the imager has a nonforeshortened image of the catheter in the parasternal long-axis view, the Impella motor speed should be temporarily set to power level P2, which reduced the risk of damaging the submitral apparatus during the catheter manipulation. Support with Impella versus intra-aortic balloon pump in acute myocardial infarction complicated by cardiogenic shock: A protocol for systematic review and meta-analysis. Assign a point person who can oversee and coordinate the program. Partner with industry. doi: 10.1097/MD.0000000000025159. 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. Diagnostic cardiac catheterization showed severe triple vessel disease as well as severe diffuse distal disease of his left internal mammary artery (LIMA) graft, his only remaining patent graft. 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.
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