Management of Patients with Impella RP Support
For patients with right ventricular failure requiring Impella RP support, management should focus on optimizing device function, maintaining appropriate anticoagulation, and monitoring for complications to reduce morbidity and mortality.
Device Indications and Selection
The Impella RP is specifically designed for patients with predominant right ventricular failure, which may occur in the setting of:
- Cardiogenic shock with right ventricular dysfunction
- Post-cardiotomy right heart failure
- Right ventricular failure after LVAD implantation
- Acute right ventricular infarction
According to the American Heart Association (AHA), the Impella RP provides mechanical circulatory support by pumping blood from the right atrium to the pulmonary artery, bypassing the failing right ventricle 1.
Initial Setup and Monitoring
Device Positioning and Function
- Confirm proper device positioning via echocardiography and chest X-ray
- Ensure adequate flow rates (typically 3-4 L/min)
- Monitor device parameters continuously:
- Motor current
- Placement signal
- Flow rate
- Purge pressure
Hemodynamic Monitoring
- Invasive arterial blood pressure monitoring
- Central venous pressure monitoring
- Daily transthoracic echocardiography to assess:
- Right and left ventricular function
- Device positioning
- Evidence of mechanical complications 1
Anticoagulation Management
Proper anticoagulation is critical for preventing thrombotic complications while minimizing bleeding risk:
Initial anticoagulation protocol:
Monitoring:
- Check anti-Xa levels or aPTT every 4-6 hours until stable, then daily
- Adjust heparin doses based on monitoring results
- Consider lower anticoagulation targets in patients with high bleeding risk
Recent evidence suggests that intermediate-range anticoagulation (aPTT 40-60s) may result in fewer bleeding complications compared to higher targets (aPTT 60-80s) without increasing thrombotic events 3.
Complication Prevention and Management
Bleeding Complications
- Monitor for access site bleeding, hemolysis, and systemic bleeding
- Maintain hemoglobin >9 g/dL
- Consider reducing anticoagulation targets if bleeding occurs
- Avoid concomitant antiplatelet therapy unless absolutely necessary
Thrombotic Complications
- Monitor for device thrombosis (increased motor current)
- Assess for limb ischemia in the cannulated extremity
- Perform regular neurological examinations to detect stroke
Infection Prevention
- Use strict aseptic technique for dressing changes
- Change dressings at the insertion site every 24-48 hours
- Monitor for signs of infection (fever, erythema at insertion site)
- Consider prophylactic antibiotics during support
Weaning Protocol
When right ventricular function improves:
- Perform echocardiography to assess RV recovery
- Gradually reduce Impella RP flow while monitoring hemodynamics
- If hemodynamics remain stable (MAP >65 mmHg, CVP <15 mmHg), consider device removal
- Device removal can be performed at the bedside without requiring reoperation 4
Special Considerations
Biventricular Support
- For patients requiring both right and left ventricular support, the Impella RP can be used in conjunction with left-sided devices
- In cases of biventricular failure, consider:
- Bilateral Impella pumps
- VA-ECMO with concomitant LV venting mechanism 1
Respiratory Failure
- For patients with concurrent respiratory failure, VA-ECMO may be more appropriate than Impella RP alone 1
Multidisciplinary Team Approach
Successful management requires coordination between:
- Cardiologists
- Cardiac surgeons
- Critical care specialists
- Perfusionists
- Specialized nursing staff
Regular team meetings to discuss device function, weaning potential, and complications are essential for optimizing outcomes.