What to do if a patient with an Impella (Intra-Aortic Balloon Pump) device goes into cardiac arrest?

Management of Cardiac Arrest in a Patient with an Impella Device

For patients with an Impella device who experience cardiac arrest, standard ACLS protocols should be followed with additional considerations for the mechanical support device, including the use of mechanical CPR devices and consideration of ECPR as a rescue therapy when initial resuscitation efforts fail. 1, 2

Initial Management

• Initiate standard ACLS protocols including high-quality CPR, defibrillation for shockable rhythms, and administration of appropriate medications per ACLS algorithms 1
• Consider using mechanical CPR devices to provide consistent chest compressions, which may be particularly beneficial as they allow for continued fluoroscopy without radiation exposure to personnel if in a catheterization lab setting 1
• Continue Impella support during resuscitation efforts as it may provide some degree of circulatory support even during cardiac arrest 2, 3

Advanced Management Considerations

• If initial resuscitation efforts fail, consider escalation to ECPR (Extracorporeal CPR) as a rescue treatment, particularly if the arrest occurred during PCI 1
• For patients with suspected calcium channel blocker toxicity contributing to cardiac arrest with an Impella in place, administer IV calcium and consider lipid-emulsion therapy 1
• Maintain anticoagulation during resuscitation to prevent pump thrombosis, typically with unfractionated heparin 4, 2

Post-Resuscitation Care

• After ROSC (Return of Spontaneous Circulation), assess for:
  • Improvement in left ventricular function via echocardiography 4, 2
  • Resolution of any mechanical complications 4
  • Need for additional hemodynamic support 2, 5
• Consider combination therapy with IABP (Intra-Aortic Balloon Pump) in addition to Impella for enhanced circulatory support in cases of refractory cardiogenic shock post-arrest 5, 6

Special Considerations

• Mortality is high (reported at 86%) in patients who have an Impella placed during active CPR, compared to 56% when placed after ROSC 3
• Monitor for potential complications including:
  • Vascular complications, which are more common with Impella compared to IABP (9.8% vs 3.8%) 4, 2
  • Bleeding complications, particularly with dual mechanical support devices 7
• Institutional guidelines should include appropriate candidate selection for mechanical support devices to ensure they are used as a bridge to recovery, surgery, transplant, or other device 1, 2

Comparison with Other Mechanical Support Options

• Impella provides greater left ventricular support than IABP but may have more complications 2, 8
• VA-ECMO provides biventricular support and may be superior for full circulatory support during prolonged resuscitation 2
• The combination of ECPR and IABP has been associated with increased survival compared to IABP alone for patients with cardiogenic shock, including those who have cardiac arrest during PCI 1

When managing cardiac arrest in a patient with an Impella device, the integration of standard ACLS protocols with specialized mechanical support considerations is essential for optimizing outcomes in these complex, high-mortality scenarios.