What is the Impella (Intra-Aortic Balloon Pump)?

From the Guidelines

The Impella device is recommended for use in patients with severe heart failure or cardiogenic shock who require temporary mechanical circulatory support, as it provides direct unloading of the left ventricle and improves end-organ perfusion, as shown in the 2022 ACC/AHA/SCAI guideline for coronary artery revascularization 1. The Impella is a catheter-based miniature heart pump that's inserted percutaneously through the femoral artery and positioned across the aortic valve. The device works by drawing blood from the left ventricle and expelling it into the ascending aorta, effectively increasing cardiac output, reducing left ventricular workload, and improving end-organ perfusion. Impella devices come in different sizes with varying flow capacities, ranging from 2.5 to 5.0 liters per minute. They're typically used as a bridge to recovery, bridge to decision, or bridge to more definitive therapy like LVAD implantation or heart transplantation. Some key points to consider when using the Impella device include:

• The need for anticoagulation, usually with heparin to maintain an ACT of 160-180 seconds, to prevent thrombus formation, as noted in the 2012 American Heart Association scientific statement on mechanical circulatory support 1.
• The potential for complications such as bleeding, vascular complications, hemolysis, and device migration, as highlighted in the 2022 ACC/AHA/SCAI guideline for coronary artery revascularization 1.
• The importance of regular assessment of hemodynamics, device function, and patient's clinical status during Impella support, as emphasized in the 2022 guideline 1.
• The limited evidence supporting the routine use of hemodynamic support devices for complex PCI, as shown in the PROTECT II trial and observational studies 1. However, the Impella device can provide hemodynamic support in select patients during complex PCI with multivessel disease, left main disease, or disease of the last patent conduit and severe left ventricular dysfunction or cardiogenic shock, as noted in the 2022 guideline 1.

From the Research

Impella Device Overview

• The Impella device is a percutaneously inserted ventricular assist device (VAD) used in patients with severe heart failure, cardiogenic shock, and high-risk percutaneous intervention (PCI) 2.
• It has been increasingly used to provide temporary mechanical circulatory support (TMCS) in the management of cardiogenic shock (CS) and high-risk percutaneous coronary interventions (PCI) 3.

Clinical Applications

• The Impella device has been used as a bridge to decision (BTD) in decompensated advanced heart failure patients, providing temporary hemodynamic support until a more permanent solution can be implemented 4.
• It has also been used to support patients undergoing high-risk PCI, providing prophylactic support to prevent cardiogenic shock 5.
• The device has been shown to be effective in obtaining hemodynamic stability in high-risk patients undergoing PCI, with some studies suggesting that earlier Impella implantation after cardiac arrest may provide cardiac support and tissue perfusion until recovery or high-risk PCI 2, 3.

Device-Specific Information

• There are several types of Impella devices, including the Impella 2.5, Impella CP, Impella 5.0/Left Direct (LD), Impella RP, and Impella 5.5, each with its own specifications and hemodynamic profiles 3.
• The choice of device depends on the specific clinical context and the patient's needs, with some devices providing more support than others 3.

Outcomes and Complications

• Studies have shown that the use of Impella devices can improve survival rates in patients with cardiogenic shock, with some studies reporting improved outcomes compared to historical controls 4, 5, 3.
• However, the use of Impella devices is not without complications, with bleeding and hemolysis being common device-related complications 4, 5.