Impella RP for Right Ventricular Failure
The Impella RP should be deployed in patients with severe right ventricular failure who remain in refractory cardiogenic shock despite maximal medical therapy (inotropes and vasopressors), particularly in the settings of post-LVAD implantation, acute myocardial infarction with RV involvement, post-cardiotomy shock, or massive pulmonary embolism. 1
Primary Indications for Impella RP Deployment
The Impella RP is specifically designed for right ventricular mechanical support and should be considered in the following clinical scenarios 1:
Post-LVAD Implantation RV Failure
- Deploy when RV failure develops after LVAD placement and fails to respond to 3-4 inotropes/vasopressors 2
- This represents one of the most common indications, with 72% survival at 30 days in prospective studies 2
- The device provides immediate hemodynamic improvement with cardiac index increasing from 1.9 to 3.1 L/min/m² and CVP decreasing from 19 to 13 mmHg 2
Acute Myocardial Infarction with RV Involvement
- Use in inferior STEMI with unsuccessful RCA revascularization (TIMI flow <3) complicated by refractory RV failure 3
- Deploy immediately in the catheterization laboratory when shock develops despite IABP and inotropes 3
- Studies show 80% RV recovery and 100% 30-day survival in this specific population 3
- However, MI-related cardiogenic shock overall has worse outcomes, particularly with cardiac arrest (25% survival) 4
Post-Cardiotomy RV Failure
- Implement when RV dysfunction persists after cardiac surgery despite maximal inotropic support 2, 4
- This includes post-heart transplant RV failure 2
- Average support duration is 4 days with favorable outcomes 2
Massive Pulmonary Embolism
- Consider in massive PE with persistent shock and RV failure refractory to medical therapy 4
- This indication shows improved survival compared to MI-related shock 4
Hemodynamic Criteria for Deployment
Deploy Impella RP when the following hemodynamic parameters are present despite maximal medical therapy 2:
- Central venous pressure ≥16-19 mmHg 3, 2
- Cardiac index <2.0 L/min/m² 2
- Systolic blood pressure <90-100 mmHg 3
- Elevated lactate >4.0 mg/dL indicating end-organ hypoperfusion 3
- Requirement for ≥3 inotropes/vasopressors 2
Timing of Deployment
Early deployment is critical—place the device immediately when refractory shock is recognized rather than waiting for further deterioration 3:
- In 80% of successful cases, Impella RP was placed immediately after failed PCI in the catheterization laboratory 3
- Delayed placement after prolonged shock is associated with worse outcomes 4
- Survival improved during later experience (last year) compared to initial 2 years, suggesting a learning curve favoring earlier deployment 4
Biventricular Support Strategy
When both LV and RV failure are present, combine Impella RP with left-sided mechanical support 5, 1:
- Use bilateral Impella pumps (Impella CP/5.0 for LV + Impella RP for RV) 1
- Alternatively, combine with VA-ECMO, though this requires careful monitoring for LV distension 5, 1
- The American Heart Association specifically identifies Impella RP as the device for cardiogenic shock with predominant RV failure 5
Expected Hemodynamic Response
Immediate hemodynamic improvement should occur within minutes of device activation 3, 2:
- Systolic blood pressure increase from ~90 to ~135 mmHg 3
- CVP decrease from ~19 to ~13 mmHg 2
- Cardiac index increase from ~1.9 to ~3.1 L/min/m² 2
- Lactate normalization from ~4.5 to ~1.6 mg/dL 3
If these improvements do not occur, reassess device position and function immediately 1.
Duration of Support and Weaning
Average support duration is 4-7 days, with weaning attempted once hemodynamics stabilize and inotrope requirements decrease 3, 2:
- Mean duration in successful cases: 7 days for MI-related RVF 3
- Mean duration across all indications: 4 days 2
- RV recovery occurs in 80% of appropriate candidates 3
- Overall 30-day survival is 72% in prospective studies 2
Critical Complications to Monitor
Bleeding and hemolysis are the most common complications requiring vigilant monitoring 6, 7:
- Bleeding requiring transfusion occurs in 42.9-63.6% of patients 6, 7
- Hemolysis develops in 86.4% of patients 7
- Vascular complications occur in 22.8% of cases 6
- Device-related failures include fracture/damage (34.2%), thrombus formation (17.1%), and device detachment (8.6%) 6
Monitor plasma-free hemoglobin, LDH, and haptoglobin levels closely 7.
Contraindications
Do not deploy Impella RP in patients with 1, 8:
- Severe peripheral artery disease preventing femoral access
- Uncorrectable causes of heart failure
- Multi-organ failure with no recovery potential 8
- Pre-existing severe renal dysfunction (though 68.2% required hemodialysis during support) 7
Anticoagulation Protocol
Initiate UFH bolus of 100 U/kg (maximum 5000 U) at implantation to prevent pump thrombosis 1:
- Continue therapeutic anticoagulation throughout support duration
- Balance thrombotic risk against the high bleeding complication rate (42.9-63.6%) 6, 7
- Adjust based on bleeding complications while maintaining minimum anticoagulation to prevent device thrombosis 1
Outcomes by Indication
Survival varies significantly by indication, guiding patient selection 4:
- Post-LVAD RV failure: 72% 30-day survival 2
- Unsuccessful RCA revascularization: 100% 30-day survival 3
- Massive pulmonary embolism: Improved survival 4
- MI-related cardiogenic shock: Worst outcomes, especially with cardiac arrest (25% survival) 4
- Post-cardiotomy (non-LVAD): Intermediate outcomes 4
Bridge-to-Decision Strategy
Use Impella RP as a bridge-to-decision device to stabilize hemodynamics while determining definitive therapy 1: