What is the optimal management strategy for a patient with an Impella (intra-aortic balloon pump) device?

Managing an Impella Device

All patients with Impella devices must be managed in a level 1 shock center with a multidisciplinary team including interventional cardiologist, cardiothoracic surgeon, cardiac intensivist, and advanced heart failure specialist, with 24/7 cardiac catheterization capability. 1

Device Selection and Hemodynamic Assessment

Choose the Impella model based on body surface area, shock severity, and whether biventricular support is needed (Impella 2.5 provides 2.5 L/min, CP provides higher flow, 5.0 provides 5.0-5.5 L/min, and RP for right ventricular support). 1, 2

Use invasive hemodynamic monitoring to guide device selection and management:

• Cardiac power output via pulmonary artery catheter is critical for both device selection and weaning strategies 3, 1
• Lactate levels and pulmonary arterial pulsatility index facilitate MCS selection 3
• Monitor cardiac output, cardiac index, mean arterial pressure (target >65 mmHg), and end-organ perfusion markers continuously 1, 2

Anticoagulation Protocol

Initiate unfractionated heparin bolus of 100 U/kg (maximum 5000 U) at time of implantation to prevent pump thrombosis. 1, 2, 4

Balance thrombotic versus bleeding risk through:

• Serial hemoglobin monitoring 1
• Vascular access site assessment 1
• Recognition that severe bleeding occurs in 8.5% and vascular complications in 9.8% of Impella patients 2, 4

Alternative anticoagulation with argatroban in the purge solution can be used for suspected heparin-induced thrombocytopenia. 5

Hemodynamic Management and Vasopressor Selection

When additional vasopressor support is needed, use 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, 2

Monitor motor current continuously as it reflects the work required to overcome the pressure gradient and indicates device function. 2

Troubleshooting and Complication Management

Watch for device malfunction including:

• Suction events occur when the device inlet becomes obstructed despite high motor currents 2
• Aortic insufficiency can develop with prolonged Impella support 2
• Position monitoring via fluoroscopy or echocardiography to ensure proper placement 6

For vascular access complications:

• The axillary artery is a suitable alternative conduit when iliofemoral vasculature is prohibitive, facilitating earlier ambulation and improved nutritional status 3
• Strict adherence to best vascular access and closure practices is critical 3

Escalation Strategies for Deteriorating Patients

When a patient deteriorates despite Impella support, immediately assess for device malfunction, inadequate flow capacity, and consider escalation to higher-flow Impella models or VA-ECMO with LV venting. 2

For biventricular failure:

• Add Impella RP to create biventricular support with bilateral Impella pumps 2
• Consider VA-ECMO, but maintain the Impella device or add IABP as an LV venting mechanism to prevent left ventricular distension 2, 4

Weaning Protocol

Assess for improvements in left ventricular function through serial echocardiographic evaluations and resolution of mechanical complications before weaning. 1, 2

Use lactate clearance and cardiac power output to guide weaning strategies. 3, 1

For patients who fail initial weaning attempts, consider longer support duration or transition to more durable mechanical circulatory support devices. 2, 4

Cardiac Arrest Management in Patients with Impella

Initiate standard ACLS protocols including high-quality CPR, defibrillation for shockable rhythms, and appropriate medications per ACLS algorithms. 4

Consider mechanical CPR devices to provide consistent chest compressions, particularly beneficial in catheterization lab settings. 4

Escalate to ECPR as rescue treatment if initial resuscitation efforts fail, particularly if arrest occurred during PCI. 4

A multidisciplinary approach to management is recommended with emphasis on evaluation of overall prognosis, likelihood of meaningful neurological recovery, and candidacy for revascularization and device-based therapies. 3

Outcomes and Bridge Strategies

Deploy MCS selectively after expedited consultation with the multidisciplinary shock team. 3

Impella may be utilized as bridge to myocardial recovery, cardiac replacement therapy, or as temporizing measure to assess candidacy for durable ventricular assist device or cardiac transplantation. 3

Overall 30-day survival is 67-72% with Impella support in severe cardiogenic shock, with survivors less likely to require mechanical ventilation or continuous renal replacement therapy. 1, 2