When is the Impella (Intra-Aortic Balloon Pump) device usually removed?

Impella Device Removal Timing

The Impella device is typically removed when there is evidence of myocardial recovery, which occurs in approximately 72% of patients, with the average duration of support ranging from 2-3 days for most acute cases to up to several weeks for bridge-to-recovery or bridge-to-transplant cases. 1

Indications for Removal

• Removal is indicated when hemodynamic parameters have normalized and there is evidence of adequate native cardiac function without mechanical support 2
• For patients who received Impella for high-risk PCI, the device is typically removed at the bedside or in the catheterization laboratory immediately following the procedure 2
• In cardiogenic shock cases, removal occurs when:
  • Vasopressor requirements have significantly decreased or been eliminated 1
  • Echocardiographic evidence shows improved ventricular function 3
  • End-organ perfusion has been restored with normalized lactate levels 3

Timing of Removal Based on Clinical Scenario

Post-PCI Support

• For elective high-risk PCI cases, the Impella is typically removed immediately after the procedure or within 24 hours 2
• The device can be safely removed at the bedside without surgical intervention 2

Cardiogenic Shock

• In cardiogenic shock cases, the average duration of support is 2-3 days before removal 1
• Removal occurs when:
  • Hemodynamic stability is achieved without significant inotropic support 3
  • Evidence of myocardial recovery is present on echocardiography 1
  • End-organ function has improved 3

Bridge to Recovery

• For fulminant myocarditis or other potentially reversible causes of cardiogenic shock, the device may remain in place for 48-72 hours before removal 4
• In some cases, the Impella may be used in combination with ECMO, with both devices typically removed within 48-72 hours once recovery is evident 4

Bridge to Decision or Bridge to Transplant

• For patients awaiting heart transplantation or long-term VAD placement, the Impella 5.5 can remain in place for extended periods
• Recent evidence shows successful use of Impella 5.5 for an average of 70 days (with maximum reported duration of 83 days) as a bridge to heart transplantation 5

Transition to Other Support Modalities

• In approximately 8% of cases, patients are transitioned from Impella to long-term ventricular assist devices when recovery is not achieved 1
• For patients with biventricular failure, the Impella may be removed and replaced with more comprehensive support systems like BiVAD or total artificial heart 3

Complications Affecting Removal Timing

• Device malfunction, high purge pressures, tube fracture, or groin hematoma may necessitate earlier than planned removal in approximately 30% of cases 1
• If thrombotic complications develop, immediate removal may be required 2

Monitoring During and After Removal

• Close hemodynamic monitoring is essential during and after Impella removal to detect any deterioration requiring reinsertion or escalation of support 3
• Echocardiographic assessment before, during, and after removal helps confirm adequate native cardiac function 3

Special Considerations

• For Impella 2.5 devices (lower flow), earlier removal may be necessary if inadequate support is provided, particularly in patients with large body mass index or severe shock 2
• For Impella 5.0/5.5 devices (higher flow), longer duration support is possible with lower complication rates compared to earlier generation devices 5