What are the next steps for a patient worsening on Impella (Intra-Aortic Balloon Pump) support?

Management of Patients Worsening on Impella Support

When a patient deteriorates despite Impella support, immediately assess for device malfunction, inadequate flow capacity for the degree of shock, and consider escalation to higher-flow Impella models or alternative mechanical circulatory support such as VA-ECMO with LV venting. 1, 2

Immediate Assessment Steps

Verify Device Function and Position

• Place a stethoscope over the pump to confirm the mechanical hum of proper functioning and check for adequate arterial flow using clinical examination or Doppler 3
• Assess hemodynamics including cardiac output, cardiac index, mean arterial pressure (target >65 mmHg), and end-organ perfusion markers 2
• Monitor motor current on the Impella controller, as this reflects the work required to overcome the pressure gradient and can indicate suction events or malposition 2
• Evaluate for new pericardial effusion or change in waveform on the controller placement signal, which may indicate catastrophic complications like ventricular perforation 4

Rule Out Technical Problems

• Verify all power cables are properly connected with adequate battery power or AC connection, ensuring the percutaneous lead is intact and not damaged 3
• Check for suction alarms indicating the device inlet has become obstructed despite high motor currents 2
• Consider exchanging the controller for the backup controller if alarms persist after confirming power supply 3

Escalation Strategy Based on Flow Inadequacy

Upgrade to Higher-Flow Impella Device

• If the patient has Impella 2.5 (maximum 2.5 L/min) and remains unstable with multiorgan failure, upgrade to Impella CP (up to 3.5 L/min) or Impella 5.0/5.5 (up to 5.0+ L/min) for greater hemodynamic support 2, 5
• This approach has demonstrated significant improvement in hemodynamics and cardiac function in critically ill patients with severe cardiogenic shock 5
• Impella 5.5 can be safely used beyond the FDA-approved 14 days, with 75% of patients supported >14 days achieving favorable outcomes (recovery or successful bridge to heart replacement therapy) 6

Add or Transition to VA-ECMO

• For patients with biventricular failure or those requiring greater systemic circulatory support than Impella alone can provide, consider VA-ECMO 1
• VA-ECMO requires close monitoring for LV distension and worsening pulmonary edema; maintain the Impella device or add an IABP as an LV venting mechanism 1, 2
• This combination prevents left ventricular distension that can occur with VA-ECMO alone 1

Address Right Ventricular Failure

• If predominant right ventricular failure develops or worsens, add Impella RP (right-sided support) to create biventricular support with bilateral Impella pumps 1, 2
• Alternatively, consider TandemHeart Protek-Duo percutaneous right ventricular assist device 1

Optimize Medical Management

Vasopressor Selection

• When additional vasopressor support is needed, prefer vasopressin or norepinephrine as they increase systemic afterload without significantly increasing pulmonary vascular resistance 2
• Avoid excessive inotrope use that increases myocardial oxygen demand 1

Anticoagulation Management

• Maintain therapeutic anticoagulation with unfractionated heparin to prevent pump thrombosis (initial bolus 100 U/kg, maximum 5000 U) 2, 7
• Balance bleeding risk (8.5% severe bleeding with Impella vs 3.0% with IABP) against thrombotic complications 2

Evaluate for Mechanical Complications

Echocardiographic Assessment

• Perform serial echocardiography to assess for improvements in left ventricular function, development of aortic insufficiency (which can develop with prolonged Impella support), or mechanical complications 2
• Evaluate for left ventricular thrombus, which is a contraindication to continued Impella use 2

Common Pitfalls to Avoid

• Do not assume the device is functioning properly based solely on controller display; always correlate with clinical examination and hemodynamics 3, 8
• Avoid excessive tension, kinking, or cutting of the percutaneous lead during patient repositioning 3
• Recognize that pump stoppage can result in thrombus formation, and restarting after prolonged stoppage risks stroke or systemic thromboembolism 3

Bridge to Definitive Therapy

Consider Durable Support or Transplant

• For patients failing initial weaning attempts despite optimization, consider longer support duration or transition to more durable mechanical circulatory support devices as a bridge to recovery, surgery, or transplant 2, 7
• Institutional guidelines should include appropriate candidate selection to ensure devices are used as a bridge to recovery, surgery, transplant, or other device 7
• Patients with heart failure-related cardiogenic shock supported with Impella 5.5 for >14 days had 80% survival with 58% successfully bridged to heart replacement therapy 6

Transport Considerations

• If persistent controller or pump malfunction occurs despite troubleshooting, immediately evaluate at the nearest center with mechanical circulatory support experience 3
• Transport unstable patients to the nearest hospital for stabilization, ensuring all peripheral equipment accompanies the patient 3
• Always manage care in collaboration with the mechanical circulatory support center in the setting of pump failure 3