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. The left main lesion was crossed, and one stent was deployed at the lesion. The SVG was aspirated before a distal protection device was placed. Our facility has a high-volume interventional cardiology program as well as a busy adult and pediatric cardiovascular surgery service. BX ct6J*0-ni0i6,,&%5y *P Garan AR, Kanwar M, Thayer KL, et al. 0000004020 00000 n 6, 7 However, the device may migrate out of . None of the patients had hemodynamic instability develop during the procedure. 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 Impella TM Device. Use of the Impella 2.5 in High-Risk - Critical Care Nursing SyBbhD&,V}R#Ohov]F}9v_c- Impella Management for the Cardiac Intensivist : ASAIO Journal - LWW A low purge pressure alarm indicates that the purge pressure to the Impella motor has decreased below 300 mm Hg. Identification of Cardiogenic Shock There are two indications for anticoagulation when using the Impella catheter. Information about the alarm can be seen on the console screen. eCollection 2021. bXSG. Impella Flashcards | Quizlet He declined repeat bypass surgery. 2 main types of pumps currently used: 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. 8600 Rockville Pike An additional method to ensure proper depth is to interrogate the aortic root with color Doppler from the parasternal long-axis view. Arterial repair is done at that time, and the incision is covered with a sterile dressing. It is useful in patients undergoing high-risk PCIs. Perioperative Management of Patients Receiving Short-term Mechanical During this time, transient no-reflow developed. Ventricular Assist Device (VAD) LITFL CCC Equipment The Impella console powers the microaxial blood pump and monitors the functioning of the device, including the purge pressure and several other parameters. Indications 1. 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. 2. position is wrong. Our training for staff from the catheterization laboratory consisted of a 3-hour session with didactic and hands-on training. 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 . The cannula appears as two bright echogenic, parallel lines, sometimes referred to as the railroad tracks, which ends at the inlet area. 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. PDF PART 9 IMPELLA TROUBLESHOOTING AND RESUSCITATION - European Society of doi: https://doi.org/10.4037/ccn2011293. 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. Rao P, Khalpey Z, Smith R, Burkhoff D, Kociol RD: Venoarterial extracorporeal membrane oxygenation for, 7. The second indication is to prevent clot formation on the catheter itself and potential embolization into the patient. *; Barnett, Christopher F.; Tuli, Aakash; Vavilin, Ilan; Kenigsberg, Benjamin B. In our facility, physicians who can place this device are those who have interventional cardiology and/or cardiac surgery privileges. 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). 29. Context 1. . The placement signal will show depressed cardiac function, evidenced by a damped appearing waveform. 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. On arrival, his blood pressure was 105/66 mm Hg with a heart rate of 64/min. If the patient tolerates this slow weaning by remaining hemodynamically stable while at P2, the device is then removed. Please try after some time. Notably, low native heart pulsatility may similarly trigger either the Impella Position Wrong or the Impella Position Unknown alarm, as the software cannot interpret the dampened amplitude of the placement signal and motor current (Figure 3E). This arrangement allowed ample time for setting up the console and infusion pump before the Impella was placed. Diastolic LV numbers are also very negative and the Max and Min flows displayed on the console are lower than expected. 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 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. Note: consider the diagnosis of normotensive cardiogenic shock when normal BP but rising lactate and transaminitis. 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. 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. Distal pulses of the affected leg should be assessed at least hourly. His ventricular function was poor with a calculated ejection fraction of 20%. 0000005740 00000 n Suction events are mostly due to abnormal device position or insufficient preload. Disclosure: The authors have no funding or conflicts of interest to report. Serum level of lactate was lower in patients treated with the Impella. 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. 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. If Impella malposition is suspected, use echo to look for inlet or outlet obstructions. Low purge pressures require immediate intervention by a critical care nurse. Some patients on Impella support may be intubated and receiving mechanical ventilation. 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). In Europe, the Impella 2.5 is approved for use up to 5 days. Patients who have had the device in longer or who were in unstable condition during the procedure may benefit from a slower weaning process. At the end of rapid weaning, the Impella device can then be removed as described in the next section. 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. 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. The use of anticoagulation is required, and bleeding may develop in some patients. Expert Rev Med Devices. Additionally, I share our experiences as we developed our Impella program at our community hospital. Hemolysis can be mechanically induced when red blood cells are damaged as they pass through the microaxial pump. The use of continuous cardiac output monitoring may be useful for patients with cardiogenic shock. 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. To date, we have placed an Impella 2.5 in about 40 patients. 2). The following 3 case studies demonstrate the successful use of Impella 2.5 support during high-risk PCIs at our facility. Abiomed Impella 2.5 Flashcards | Quizlet 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. Six weeks later, the patient was pain free with no complaints of dyspnea. ?(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 Impella - critical care notes Disclaimer. To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. b)x""o0``k1h^xyW 3. placement monitoring is suspended or disabled. Parameters to assess regularly include placement signal, placement monitoring (pump position), dual signal, purge pressure, motor current, and speed (Table 6).
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