What are the key considerations in managing a patient with an Impella (Intra-Aortic Balloon Pump) RP (Right Ventricular Support Device)?

Management of Patients with Impella RP Support

The management of patients with an Impella RP device requires a standardized approach focusing on proper device positioning, anticoagulation management, complication monitoring, and systematic weaning protocols to optimize outcomes and reduce mortality in patients with right ventricular failure. 1

Device Positioning and Monitoring

• Initial positioning verification:

  • Confirm proper device positioning via echocardiography and chest X-ray immediately after placement 1
  • Ensure the inlet area is positioned in the right atrium and the outlet area in the pulmonary artery

• Ongoing monitoring:

  • Perform daily transthoracic echocardiography to assess:
    • Right and left ventricular function
    • Device positioning
    • Evidence of mechanical complications 1
  • Monitor device parameters continuously:
    • Motor current
    • Placement signal
    • Flow rate
    • Purge pressure 1

Hemodynamic Management

• Invasive monitoring:

  • Maintain invasive arterial blood pressure monitoring
  • Monitor central venous pressure 1
  • Consider pulmonary artery catheterization for comprehensive hemodynamic assessment 2

• Volume status:

  • Maintain euvolemia with central venous pressure of 8-12 mmHg 2
  • Avoid excessive volume loading which may worsen RV dilation and tricuspid regurgitation 2
  • Consider diuresis to reduce ventricular dilation and improve biventricular coupling 2

Anticoagulation Management

• Standard anticoagulation:

  • Maintain systemic anticoagulation to prevent device thrombosis
  • Monitor anticoagulation parameters regularly (ACT, PTT) 1

• Special situations:

  • For patients with heparin-induced thrombocytopenia (HIT):
    • Consider alternative anticoagulants such as bivalirudin or argatroban in the purge solution 3, 4
    • Monitor purge flow and pressure closely as non-heparin alternatives may affect device performance 4

• Bleeding management:

  • Maintain hemoglobin >9 g/dL 1
  • Consider reducing anticoagulation targets if bleeding occurs
  • Monitor for access site bleeding, hemolysis, and systemic bleeding 1

Complication Prevention and Management

• Thrombotic complications:

  • Monitor for device thrombosis (changes in motor current, flow rates)
  • Ensure adequate anticoagulation 1

• Vascular complications:

  • Assess for limb ischemia, particularly at access sites
  • Perform regular neurological examinations to detect stroke 1

• Infection prevention:

  • Use strict aseptic technique for all device manipulations and dressing changes
  • Monitor for signs of infection (fever, leukocytosis, erythema at insertion site) 1

• Device-related complications:

  • Be vigilant for device-related complications which can occur in up to 46.7% of patients 5
  • Address hemolysis if present (indicated by rising LDH, falling haptoglobin)

Pharmacological Support

• Vasopressors and inotropes:

  • Consider vasopressin or norepinephrine to maintain RV perfusion during inodilator therapy 2
  • For RV-dominant failure, consider agents that increase systemic afterload without increasing pulmonary vascular resistance 2

• Pulmonary vasodilators:

  • Consider intravenous or inhaled pulmonary vasodilators to reduce RV afterload in pulmonary hypertension 2

Weaning and Device Removal

• Assessment for weaning:

  • Perform echocardiography to assess RV recovery
  • Gradually reduce Impella RP flow while monitoring hemodynamics 1

• Removal criteria:

  • Stable hemodynamics at reduced support levels
  • Improved RV function on echocardiography
  • Reduced need for pharmacological support 1

Special Considerations

• Biventricular support:

  • For patients requiring both RV and LV support, Impella RP can be used with left-sided devices 1
  • In biventricular failure, consider bilateral Impella pumps or VA-ECMO with LV venting 1, 5

• Respiratory failure:

  • For concurrent respiratory failure, VA-ECMO may be more appropriate than Impella RP alone 1
  • Consider Protek Duo with oxygenator for combined respiratory and RV support 2

Outcomes and Prognosis

• Impella RP support can result in rapid hemodynamic improvement with favorable survival rates of approximately 72% at 30 days 6
• In-hospital mortality remains significant at approximately 46.7% 5
• The device has demonstrated efficacy in various clinical scenarios including post-LVAD implantation, post-cardiotomy, post-heart transplant, and post-myocardial infarction RV failure 7, 6