Which of the following is an absolute contraindication to use of the Impella device: left ventricular thrombus, aortic valve regurgitation, aortic valve stenosis, or pericardial tamponade?

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Last updated: February 21, 2026 • View editorial policy

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Absolute Contraindications to Impella Platform Use

Aortic valve regurgitation (moderate-to-severe or greater) is an absolute contraindication to Impella use, as the device would worsen regurgitation by holding the aortic valve open and creating a continuous pathway for blood to flow back into the left ventricle, negating the device's hemodynamic benefits. 1, 2

Understanding Each Option

Left Ventricular Thrombus - ABSOLUTE CONTRAINDICATION

  • LV thrombus is definitively listed as an absolute contraindication to Impella use because the device traverses the left ventricle and could dislodge the thrombus, causing catastrophic systemic embolization including stroke. 1, 2, 3
  • The device mechanism involves aspirating blood from the LV cavity and ejecting it into the ascending aorta, making any LV thrombus a direct embolic risk. 4
  • Multiple guidelines from the American College of Cardiology and European Society of Cardiology consistently identify LV thrombus as an absolute contraindication. 1, 2
  • Case reports document the serious complications when LV thrombus develops during Impella support, requiring specialized cerebral protection strategies for device removal. 5

Aortic Valve Regurgitation - ABSOLUTE CONTRAINDICATION

  • Significant aortic insufficiency (moderate or greater) is an absolute contraindication because the Impella catheter crosses the aortic valve and holds it open during operation. 1, 2
  • The device would exacerbate existing regurgitation by creating a continuous conduit for retrograde flow from the aorta back into the LV, completely undermining the intended hemodynamic support. 3
  • This contraindication is consistently cited across American College of Cardiology, American Heart Association, and European Society of Cardiology guidelines. 1, 2, 3

Aortic Valve Stenosis - ABSOLUTE CONTRAINDICATION

  • Severe aortic stenosis is an absolute contraindication to Impella because the device must traverse the stenotic valve, which creates multiple problems. 1, 2
  • The stenotic valve prevents adequate device positioning and function, and attempting to pass the catheter through severe stenosis risks valve damage or inability to properly seat the device. 2
  • The calcified, narrowed valve orifice physically impedes the Impella catheter passage and optimal pump positioning. 1

Pericardial Tamponade - NOT Listed as Absolute Contraindication

  • Pericardial tamponade is not specifically listed as an absolute contraindication in major guidelines for Impella use. 1, 2, 3
  • However, tamponade would need to be addressed (via pericardiocentesis) before Impella insertion as part of stabilizing the patient's hemodynamics.
  • The guidelines mention calcified pericardium as a contraindication for transapical TAVI approach, but this is a different device and access route. 6

Clinical Decision Algorithm

When evaluating Impella candidacy, systematically exclude these absolute contraindications:

  1. Perform echocardiography to assess for:

    • LV thrombus (use contrast echo or CT if uncertain) 4
    • Aortic valve regurgitation severity (≥moderate is contraindication) 1
    • Aortic valve stenosis severity (severe is contraindication) 2

  2. If any of the three valve/thrombus contraindications are present, Impella is absolutely contraindicated and alternative mechanical support should be considered (VA-ECMO, surgical options). 3

  3. Additional absolute contraindications to verify:

    • Severe peripheral artery disease preventing femoral access 1, 2
    • Aortic dissection 1, 2

Critical Pitfall to Avoid

Do not assume echocardiography alone is sufficient to exclude LV thrombus - if there is any diagnostic uncertainty, obtain contrast-enhanced CT imaging before Impella insertion, as echocardiography has limited sensitivity for detecting LV thrombus. 4 The consequences of missing an LV thrombus include catastrophic stroke and systemic embolization when the device is inserted or removed. 5

References

1
Guideline

Indications for Impella in Patients with Cardiogenic Shock or High-Risk Percutaneous Coronary Intervention

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

2
Guideline

Temporary Ventricular Assist Devices with Impella

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

3
Guideline

Impella Device Overview and Clinical Applications

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

5
Research

The use of a sentinel cerebral protection system during Impella CP removal in a patient with left ventricular thrombus.

Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions, 2020

6
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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