cardiac intensive care unit; cardiogenic shock; Impella; mechanical circulatory support. 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. 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. Rao P, Khalpey Z, Smith R, Burkhoff D, Kociol RD: Venoarterial extracorporeal membrane oxygenation for, 7. PMC 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. Immediately before removal of the device, decrease the performance level to P0. Hemolysis can occur in patients who are on the Impella 2.5. Catheter position should be assessed daily and in response to unexpected clinical changes or specific device alarms. High-risk PCI - Impella 2.5, CP - < 6 hours (temporary) VAD for use during high-risk percutaneous coronary intervention (prevent hemodynamic instability) 2. Complications associated with mechanical circulatory support. He had a history of coronary artery bypass grafting surgery several years prior as well as heart failure. He was evaluated by our cardiothoracic surgery team and was deemed an extremely poor candidate for surgery. (Figure 3F). The placement signal will show a normal appearing aortic waveform with systolic and diastolic pressures similar to those shown by the patients arterial catheter. The proximal port of this lumen is red. National Library of Medicine Staff received 1-to-1 mentoring from the Impella coordinator. Additionally, cardiac resuscitation can cause device migration and as such, post-arrest ultrasound confirmation of position is recommended. Cardiogenic shock complicates 5-10% of cases of myocardial infarction 1-3 and mechanical support devices have demonstrated limited benefit with early initiation and appropriate protocols. 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). One lumen carries fluid to the impellar blades and continuously purges the motor to prevent the formation of thrombus. Furthermore, crowding of the inlet or outlet areas increases shear stress on the red blood cells pumped through the cannula, accelerating the rate of hemolysis caused by the device. Distal pulses of the affected leg should be assessed at least hourly. may email you for journal alerts and information, but is committed Percutaneous mechanical support devices are placed in a minimally invasive manner and provide life-saving assistance. 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. Abiomed also provides assistance with troubleshooting via 24-hour-a-day, 7-day-a-week telephone support. Coordination with the perfusionist is essential when patients are being placed on cardiopulmonary bypass. 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). 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. Support with Impella versus intra-aortic balloon pump in acute myocardial infarction complicated by cardiogenic shock: A protocol for systematic review and meta-analysis. Impella 2.5 cardiac assist device in left ventricle. Heparin 9000 units was administered intravenously for anticoagulation, and the Impella 2.5 was advanced into position in the left femoral artery. It cannot be used in patients with documented left ventricular thrombus. 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. 2022 Feb 28;19(2):115-124. doi: 10.11909/j.issn.1671-5411.2022.02.003. 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. echocardiography (right). Unlike the IABP, the Impella does not require timing, nor is a trigger from an electrocardiographic rhythm or arterial pressure needed (Table 1). Would you like email updates of new search results? Data is temporarily unavailable. Advanced Percutaneous Mechanical Circulatory Support Devices for Cardiogenic Shock. 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). His estimated ejection fraction was markedly decreased at 20% (normal, 55%70%) on a recent echocardiogram. The purpose of this review is to describe how to manage, reposition, and wean patients from the Impella catheter. 0000000636 00000 n Some facilities may use what is referred to as a preclose method while the patient is still in the catheterization laboratory; that technique uses 2 8F Perclose suture-mediated closure devices (Abbott Laboratories, Abbott Park, Illinois). 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 13F arterial sheath was sutured in placed for removal 4 hours later after the patient was returned to the CICU. Regular repositioning of patients and assessment of their skin are necessary to prevent skin breakdown. Just visit www.ccnonline.org and click Respond to This Article in either the full-text or PDF view of the article. doi: https://doi.org/10.4037/ccn2011293. She returned to the catheterization laboratory 3 days later for high-risk PCI of the left main coronary artery. Disclaimer. In our facility, this role is filled by the interventional cardiology clinical nurse specialist. 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. official website and that any information you provide is encrypted Despite the no-reflow, the arterial pressure, heart rate, and cardiac rhythm remained stable, and the patient had no complaints of shortness of breath or chest discomfort. Even a common cold can cause your uvula to swell. Ongoing practice is essential to develop and maintain competency. 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 VAD coordinators also provide valuable assistance. The sheath can then be removed later when the patients activated clotting time or partial thromboplastin time has returned to near normal levels. The placement signal will show depressed cardiac function, evidenced by a damped appearing waveform. 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). Automated Impella Controller (collectively, "Impella System Therapy"), are temporary ventricular support devices intended for short term use ( 4 days for the One community hospitals approach to establishing a multidisciplinary program for use of the Impella 2.5 is described. 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. 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). Additionally, I share our experiences as we developed our Impella program at our community hospital. trailer <<4E9C4E69F2794E779C95DF45DA44CC4E>]/Prev 560917/XRefStm 1133>> startxref 0 %%EOF 613 0 obj <>stream A patient experiencing continuous suction may show systolic LV numbers, shown in white, that are uncoupled from the aortic numbers shown in red. The use of anticoagulation is required, and bleeding may develop in some patients. If the hemolysis is severe, hemoglobinuria will be seen; if the hemolysis is sustained, acute kidney injury will occur. Unable to load your collection due to an error, Unable to load your delegates due to an error. Some error has occurred while processing your request. Our training for staff from the catheterization laboratory consisted of a 3-hour session with didactic and hands-on training. Like all LV assist devices, the Impella can only pump as much blood as is available to it. Now that youve read the article, create or contribute to an online discussion about this topic using eLetters. Fluoroscopic guidance in the catheterization laboratory or operating room is required. In our facility, physicians who can place this device are those who have interventional cardiology and/or cardiac surgery privileges. 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. v67z]FcUe7sne[l}g&_}V^7vk~7S/o}AoepY5OTYe>acQ*|o? \-yVJUrM^2E~,d3EN9--u1C~A+ Areas covered: Introduction: Unauthorized use of these marks is strictly prohibited. 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. The Impella 2.5 catheter has 2 lumens. Troubleshooting tips. A console simulator is available that can be used to practice troubleshooting. The motor current will be flattened. A 74-year-old man was transferred to our facility after sustaining a nonST-segment elevation myocardial infarction. E-mail: [emailprotected]; Twitter: @AlexPapolos. He declined repeat bypass surgery. If the patients ventricular function is very poor, a positioning alarm can occur. Highlight selected keywords in the article text. The Impella 2.5 catheter is placed percutaneously through the common femoral artery and advanced retrograde to the left ventricle over a guidewire. The use of two Impella devices concurrently has demonstrated decreased LV filling pressures and improved cardiac output for cardiogenic shock patients, although reported data on this use is limited and future studies are required. Brenda McCulloch; Use of the Impella 2.5 in High-Risk Percutaneous Coronary Intervention. The arterial access site must be assessed regularly for bleeding and development of a hematoma. 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. Additional torque can be achieved by rotating the red Impella plug (Figure 5) at the proximal end of the catheter in the desired direction. Catheters with SmartAssist, however, will more specifically identify the nature of the mispositioning and can distinguish between the ventricular and aortic placement of the inlet and outlet areas (Figure 3C and 3D). The PCI procedure of the LAD SVG was then started. To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Abiomed has sponsored several of these trials, including PROTECT I, PROTECT II, RECOVER I, RECOVER II, and ISAR-SHOCK. If the catheter is completely out of the ventricle, it should be repositioned across the valve over a guidewire. 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. 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. Diagnostic cardiac catheterization and coronary angiography performed at the referring facility showed severe triple vessel coronary disease and high-grade lesions in 2 SVGs. The catheter is not tethered to any internal structure and is prone to migration which occurs more frequently when the catheter is placed percutaneously. Optimal imaging often requires off-axis parasternal long-axis views obtained by fanning and rotating the probe until the entire length of the cannula and the aortic annulus are seen. 3. placement monitoring is suspended or disabled. 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. One patient died before implantation of a device. your express consent. Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints@aacn.org. Sheaths were placed in the right femoral vein, the right femoral artery, and the left femoral artery. BX ct6J*0-ni0i6,,&%5y *P 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. The patient was weaned from the Impella device, the device was removed in the catheterization laboratory, and the venous and arterial sheaths were secured in place. Console and infusion pump setup requires 2 to 3 minutes to complete. With respect to weaning order of operations, we generally favor first weaning and decannulation from VA-ECMO (if possible from a pulmonary support perspective), which is based on the higher MCS complication rates and patient immobility associated with VA-ECMO cannulation. The Suction alarm is triggered when sudden decreases in the placement signal pressure occur in association with lower than expected flows.
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