Download Use of the Impella 2.5 in High-Risk Percutaneous Coronary Intervention

Use of the Impella 2.5 in High-Risk Percutaneous Coronary Intervention
Brenda McCulloch
Crit Care Nurse 2011, 31:e1-e16. doi: 10.4037/ccn2011293
© 2011 American Association of Critical-Care Nurses
Published online http://www.cconline.org
Subscription Information
http://ccn.aacnjournals.org/subscriptions
Information for authors
http://ccn.aacnjournals.org/misc/ifora.xhtml
Submit Manuscript
www.editorialmanager.com/ccn
E-mail alerts
http://ccn.aacnjournals.org/subscriptions/etoc.xhtml
Critical Care Nurse is the official peer-reviewed clinical journal of the
American Association ofCritical-Care Nurses, published bi-monthly by
The InnoVision Group 101 Columbia, Aliso Viejo, CA 92656.
Telephone: (800) 899-1712, (949) 362-2050, ext. 532. Fax: (949)
362-2049. Copyright © 2011 by AACN. All rights reserved.
Downloaded from http://ccn.aacnjournals.org/ by guest on June 9, 2014
Feature
Use of the Impella 2.5 in
High-Risk Percutaneous
Coronary Intervention
Brenda McCulloch, RN, MSN
The Impella 2.5 is a percutaneously placed partial circulatory assist device that
is increasingly being used in high-risk coronary interventional procedures to provide
hemodynamic support. The Impella 2.5 is able to unload the left ventricle rapidly
and effectively and increase cardiac output more than an intra-aortic balloon catheter
can. Potential complications include bleeding, limb ischemia, hemolysis, and infection. One community hospital’s approach to establishing a multidisciplinary program
for use of the Impella 2.5 is described. (Critical Care Nurse. 2011;31[1]:e1-e16)
P
atients who undergo highrisk percutaneous coronary intervention (PCI),
such as procedures on
friable saphenous vein
grafts or the left main coronary
artery, may have an intra-aortic
balloon catheter placed if they
require hemodynamic support during the procedure. Currently, the
intra-aortic balloon pump (IABP)
is the most commonly used device
for circulatory support. A newer
option that is now available for select
patients is the Impella 2.5, a shortterm partial circulatory support
device or percutaneous ventricular
assist device (VAD).
In this article, I discuss the
Impella 2.5, review indications and
contraindications for its use, delineate potential complications of the
©2011 American Association of CriticalCare Nurses doi: 10.4037/ccn2011293
e1 CriticalCareNurse OnlineNOW
Impella 2.5, and discuss implications for nursing care for patients
receiving extended support from
an Impella 2.5. Additionally, I share
our experiences as we developed our
Impella program at our community
hospital. Routine management of
patients after PCI is not addressed.
IABP therapy has been in use
since the late 1960s and has been
widely used in clinical practice since
that time. The IABP decreases afterload, decreases myocardial oxygen
consumption, increases coronary
artery perfusion, and modestly
enhances cardiac output.1,2 The IABP
cannot provide total circulatory
support. Patients must have some
level of left ventricular function for
an IABP to be effective. Optimal
hemodynamic effect from the IABP
is dependent on several factors,
including the balloon’s position in
the aorta, the blood displacement
volume, the balloon diameter in
relation to aortic diameter, the timing of balloon inflation in diastole
and deflation in systole, and the
patient’s own blood pressure and
vascular resistance.3,4
The Impella 2.5 (Figure 1) aspirates up to 2.5 L/min of blood from
the left ventricle and displaces it into
the ascending aorta, rapidly unloading the left ventricle and increasing
forward flow. It reduces myocardial
oxygen consumption, improves mean
arterial pressure, and reduces pulmonary capillary wedge pressure.2
The Impella provides a greater
increase in cardiac output than the
IABP provides. In one trial5 in
which an IABP was compared with
an Impella in cardiogenic shock
patients, after 30 minutes of therapy, the cardiac index (calculated as
cardiac output in liters per minute
divided by body surface area in
square meters) increased by 0.5 in
the patients with the Impella compared with 0.1 in the patients with
an IABP. Unlike the IABP, the Impella
does not require timing, nor is a
trigger from an electrocardiographic
rhythm or arterial pressure needed
(Table 1). The device received 510(k)
clearance from the Food and Drug
Administration in June 2008 for
providing up to 6 hours of partial
www.ccnonline.org
Downloaded from http://ccn.aacnjournals.org/ by guest on June 9, 2014
cardiomyopathy
with acute
decompensation, postcardiotomy shock,
off-pump coronary artery
bypass grafting
surgery, or heart
transplant rejection and as a
bridge to the
next decision.9
Clinical
Research
and Registry
Findings
In Europe,
the Impella 2.5
has been in wide
use for several
years.8,9 In the
United States,
several small
Figure 1 Impella 2.5 cardiac assist device in left ventricle.
trials5,6,9-12 have
Image courtesy ABIOMED Inc, Danvers, Massachusetts.
been completed
or are underway
circulatory support. In Europe, the
to evaluate the Impella 2.5. Abiomed
Impella 2.5 is approved for use up to
has sponsored several of these trials,
5 days. Reports of longer duration
including PROTECT I, PROTECT II,
of therapy in both the United States
RECOVER I, RECOVER II, and
and Europe have been published.8,9
ISAR-SHOCK.
The Impella 2.5 has been used
The PROTECT I study was done
for hemodynamic support during
to assess the safety and efficacy of
high-risk PCI and for hemodynamic
device placement in patients undersupport of patients with myocardial
going high-risk PCI.10 Twenty patients
infarction complicated by cardiogenic
were enrolled in that prospective,
shock or ventricular septal defect,
multicenter study. All had poor
Author
Brenda McCulloch is a cardiovascular clinical nurse specialist at Sutter Heart and Vascular
Institute, Sutter Medical Center, Sacramento, California.
Corresponding author: Brenda McCulloch, RN, MSN, Sutter Heart and Vascular Institute, Sutter Medical Center,
5301 F Street, Suite 304, Sacramento, CA 95819 (e-mail: [email protected]).
To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656.
Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, [email protected].
ventricular function (ejection fraction ≤35%) and had PCI on an unprotected left main coronary artery or
the last remaining patent coronary
artery or graft. The device was successfully placed in all patients, and
the duration of support ranged from
0.4 to 2.5 hours. None of the patients
had hemodynamic instability develop
during the procedure. Two patients
had transient hemolysis that was
not clinically significant. Following
this trial, the Impella 2.5 device
received its 510(k) approval from
the Food and Drug Administration.
The ISAR-SHOCK trial was done
to evaluate the safety and efficacy of
the Impella 2.5 versus the IAPB in
patients with cardiogenic shock due
to acute myocardial infarction.5
Patients were randomized to support from an IABP (n=13) or an
Impella (n=12). One patient died
before implantation of a device.
The trial’s primary end point of
hemodynamic improvement was
defined as improved cardiac index
at 30 minutes after implantation.
Improvements in cardiac index were
significantly greater in the patients
with the Impella than in patients
with the IABP (P=.02). The patients’
diastolic pressure increased significantly more with Impella support
than with IABP support (P=.002).
Mean arterial pressure increased in
patients with an Impella more than
it increased in patients with an IABP,
but the difference was not significant (P=.09). The use of inotropic
agents and vasopressors was similar
in both groups of patients. Serum
level of lactate was lower in patients
treated with the Impella. Hemolysis,
as measured by the plasma level of
free hemoglobin, was higher in
patients treated with the Impella.
www.ccnonline.org
Downloaded from http://ccn.aacnjournals.org/ by guest on June 9, 2014
CriticalCareNurse OnlineNOW e2
Table 1
Comparing traditional intra-aortic balloon therapy with Impella 2.5 percutaneous ventricular assist device
Feature
Intra-aortic balloon therapy6,7
Impella 2.5
Duration of use
Short-term use: hours to days
Approved by the Food and Drug Administration for use up
to 6 hours; approved in Europe for up to 5 days
How does it work?
Blood volume displacement
Requires cardiac rhythm or arterial
pressure for trigger
Requires intermittent timing to ensure
optimal inflation and deflation of balloon
Increases cardiac output more than an intra-aortic balloon
pump does
Works independently of cardiac rhythm or arterial pressure
No timing required because it is continuous flow
Physiological impact
Decreases afterload
Augments cardiac output modestly
Moderate to severe aortic insufficiency
Abdominal or aortic aneurysm
Increases forward flow
Unloads left ventricle
Augments cardiac output
Increases mean arterial pressure
Contraindications
Moderate to severe peripheral arterial
disease
Mechanical aortic valve
Moderate to severe aortic diseease
Left ventricular thrombus
Moderate to severe peripheral arterial disease
Cost
$800-$1200 for cost of device and
associated supplies plus cost of console
$20 000-$25 000 for cost of device and associated supplies;
console provided with catheter purchase
Potential complications
Limb ischemia
Bleeding, hematoma at access site
Vascular injury
Embolization of thrombus or plaque
Infection
Balloon rupture
Limb ischemia
Bleeding, hematoma at access site
Vascular injury
Hemolysis
Embolization of thrombus or plaque
Infection
Device failure
More blood products were administered to patients treated with the
Impella.
Results from additional clinical
trials are available (Table 2), but continuing clinical trials are essential to
evaluate the effectiveness of the Impella
2.5 device in various subgroups.
Device Design
The Impella 2.5 catheter (Figure 2)
contains a nonpulsatile microaxial
continuous flow blood pump (Figure
3) that pulls blood from the left ventricle to the ascending aorta, creating
increased forward flow and increased
cardiac output. An axial pump is one
that is made up of impellar blades, or
rotors, that spin around a central
shaft; the spinning of these blades is
what moves blood through the
device.13 The distal tip of pigtail curve
is 6F in size (Figure 4). The Impella 2.5
e3 CriticalCareNurse OnlineNOW
catheter shaft size is 9F and is 12F
at its largest point, which is the
microaxial blood pump.
The Impella 2.5 catheter has 2
lumens. A tubing system called the
Quick Set-Up has been developed
for use in the catheterization laboratory. It is a single tubing system that
bifurcates and connects to each port
of the catheter. This arrangement
allows rapid initial setup of the console so that support can be initiated
quickly. When the Quick Set-Up is
used, the 10% to 20% dextrose solution used to purge the motor is not
heparinized. One lumen carries fluid
to the impellar blades and continuously purges the motor to prevent
the formation of thrombus. The
proximal port of this lumen is yellow.
The second lumen ends near the
motor above the level of the aortic
valve and is used to monitor aortic
pressure. The console uses this
pressure measurement to calculate
the catheter’s position. The proximal port of this lumen is red.
If the Impella remains in place
for continued support after the PCI,
the tubing system is changed to 2
separate systems. For continued
use, the purge fluid is heparinized
(50 units heparin per milliliter of
fluid) and infused via an integrated
infusion pump, the Braun Vista
infusion pump (Figure 5). The typical infusion rate for the purge fluid
is 7 to 20 mL/h.
The second lumen of the Impella
2.5 is flushed with heparinized
saline (500 mL normal saline with
1000 units heparin) by using regular
(not infusion pump) intravenous
tubing. The heparinized saline is
placed in a pressure bag that is
inflated to 300 mm Hg. Other
www.ccnonline.org
Downloaded from http://ccn.aacnjournals.org/ by guest on June 9, 2014
Table 2
Review of the research
Study, year
Sample size
Purpose
Findings
Henriques et al,9 2006
To evaluate safety and fea- 19 consecutive
patients undergoing
sibility of using Impella
high-risk PCI
after percutaneous coronary intervention (PCI) in
patients with ST-elevation
myocardial infarction
Remmelink et al,6 2007
Evaluate effects of left
ventricular unloading by
the Impella 2.5 on coronary hemodynamics
11 consecutive patients
who underwent elective high-risk PCI
Aortic and coronary pressures increased with
Impella support (P = .001)
Seyfarth et al,5 2008
ISAR–SHOCK,
sponsored by Abiomed
Evaluate safety and efficacy of Impella 2.5
compared with intraaortic balloon pump
(IABP) in cardiogenic
shock after acute
myocardial infarction
26 patients with cardiogenic shock after
acute myocardial
infarction; randomized to IABP (n = 13)
or Impella (n = 12)
One patient died before
implantation
Primary end point of hemodynamic improvement
(defined as improved cardiac index at 30 minutes
after implantation) was achieved in 25 patients
Mean arterial pressure increased more in patients
with Impella than in patients with the IABP, but the
difference was not significant (P = .09)
Improvement in cardiac index significantly greater in
Impella patients (P = .02)
Diastolic pressure increased significantly more with
Impella support than with IABP (P = .002)
Use of inotropic agents and vasopressors was
similar in both groups of patients
Serum level of lactate was lower in patients treated
with Impella
Hemolysis measured by plasma free hemoglobin
was higher in patients treated with Impella (P <.05)
More blood products were administered to patients
treated with Impella
Burzotta et al,11 2008
To evaluate feasibility and
long-term safety of
Impella-assisted highrisk PCI
10 consecutive
patients undergoing
elective high-risk PCI
All patients had ejection fraction ≤30%
and multivessel or
left main coronary
disease
Left ventricular ejection fraction at 6 month followup increased significantly (P = .02)
No access site complications
No blood products required
Ferreiro et al,12 2009
To evaluate the use and
safety of the Impella 2.5
in elective high-risk PCI
26 of 30 consecutive
patients who underwent high-risk PCI;
3 patients excluded
because of cardiogenic shock; 1
excluded because of
device malfunction
PCI was successfully performed in all patients:
• 88.5% remained hemodynamically stable during
procedure
• 3 patients had severe hypotension develop
because of no-reflow
• 1 patient died of intracranial hemorrhage 8 hours
after the Impella was removed
• 3 patients had limb ischemia develop; 1 required
surgical intervention
• 1 patient had hemolysis develop that required
blood transfusion
components of the Impella 2.5
catheter include the cable that connects the catheter to the console and
a repositioning sheath for bedside
repositioning of the Impella 2.5.
The components required to
run the device are assembled on a
Successful placement achieved in all patients
No major complications related to the Impella
developed in any patients
Bleeding developed in 1 patient who required a
blood transfusion
2 patients died of causes not related to the Impella
rolling cart (Figure 6) and include
the power source, the Braun Vista
infusion pump, and the Impella
console (Figure 7). The Impella console powers the microaxial blood
pump and monitors the functioning
of the device, including the purge
pressure and several other parameters. The console has 10 function
keys, but not all of the function keys
are used for the Impella 2.5. Some
were designed to support future versions of Impella catheters. Function
keys that are used with the Impella
www.ccnonline.org
Downloaded from http://ccn.aacnjournals.org/ by guest on June 9, 2014
CriticalCareNurse OnlineNOW e4
Red pressure sideport
Repositioning unit
Sideport to
hemostasis sheath
Plug to console
Infusion filter
Hemostasis sheath
Pressure
reservoir
Pigtail tip
Inlet area
Valve to
purge fluid
Outlet area
Blood pump
Placement markings
on the catheter shaft
Figure 2 Components of the Impella 2.5 cardiac assist device.
Image courtesy ABIOMED Inc, Danvers, Massachusetts.
2.5 include the P-PERF, MENU,
SIGNAL, SCALE, and the ON keys.
The console can run on a fully
charged battery for up to 1 hour.
Figure 3 Blood pump used in the
Impella 2.5.
Placement of the Device
The Impella 2.5 catheter is placed
Image courtesy ABIOMED Inc, Danvers, Massapercutaneously through the comchusetts.
mon femoral artery and advanced
retrograde to
the left ventricle
over a guidewire.
Fluoroscopic
guidance in the
catheterization
Inlet area
laboratory or
operating room
is required. After
the device is
properly posiMicroaxial blood pump
tioned, it is activated and blood
is rapidly withOutlet area
drawn by the
Open pressure area
microaxial blood
pump from the
Figure 4 Detailed view of distal end of Impella 2.5.
inlet valve in the
Image courtesy ABIOMED Inc, Danvers, Massachusetts.
left ventricle and
e5 CriticalCareNurse OnlineNOW
moved to the aorta via the outlet
area, which sits above the aortic
valve in the aorta (Figure 8).
If the patient tolerates the PCI
procedure and hemodynamic instability does not develop, the Impella
2.5 may be removed at the end of
the case while the patient is still in
the catheterization laboratory. The
Impella device can be withdrawn,
leaving the arterial sheath in place.
The sheath can then be removed
later when the patient’s activated
clotting time or partial thromboplastin time has returned to near
normal levels. For patients who
become hemodynamically unstable
or who have complications during
the PCI (eg, no reflow, hypotension,
or lethal arrhythmias), the device
can remain in place for continued
partial circulatory support, and the
patient is transported to the critical
care setting.
Contraindications
The Impella 2.5 cannot be used
on all acutely ill patients who require
hemodynamic support.14 Because
the device is designed to sit across
the aortic valve in the left ventricle,
it should not be used in patients
who have prosthetic aortic valves,
so as to prevent damage to the valve.
It should not be used in patients
with moderate to severe aortic
insufficiency; it may worsen the
degree of insufficiency because the
aortic valve cannot close completely
with the device in place. The Impella
should not be used in patients with
a heavily calcified aortic valve. The
device may cause calcium to break
off of the aortic valve and embolize,
causing stroke. It cannot be used in
patients with documented left ventricular thrombus. The impellar
www.ccnonline.org
Downloaded from http://ccn.aacnjournals.org/ by guest on June 9, 2014
Figure 5 Braun Vista infusion pump.
Image courtesy ABIOMED Inc, Danvers, Massachusetts.
blades of the
motor could
break up the
thrombi, causing arterial
embolization.
The device also
cannot be used
in patients with
severe peripheral
arterial disease
because of the
large sheath size
required for its
placement, nor
can it be used in
patients who
cannot tolerate
anticoagulation
with heparin.
Potential Complications of
Impella Therapy
Figure 6 Rolling cart carrying components required to run the Impella 2.5.
Image courtesy ABIOMED Inc, Danvers, Massachusetts.
Potential complications of use of the
Impella 2.5 are detailed in Table 3.
Nursing Care of Patients
With an Impella 2.5 for
Circulatory Support
The nursing care of patients
remaining on Impella 2.5 support
requires astute assessment and
expert nursing care (Table 4). Frequent hemodynamic evaluation is
needed. The use of continuous cardiac output monitoring may be
useful for patients with cardiogenic
shock. Inotropic agents, such as
dobutamine and milrinone, and
vasopressors, such as dopamine and
norepinephrine, may still be needed
after the Impella 2.5 is placed to
maintain a cardiac index of at least
2 and systolic blood pressure at 90
mm Hg or higher. Some patients on
Impella support may be intubated
and receiving mechanical ventilation.
Implementation of the ventilator
The most commonly reported
complications of Impella 2.5 placement and support include
limb ischemia,
vascular injury,
and bleeding
requiring blood
transfusion.6,9
Hemolysis has
been reported.5,10
Other potential
complications
include aortic
valve damage,
displacement of
the distal tip of
the device into
the aorta, infection, and sepsis.
Device failure,
although not
Figure 7 Console of the Impella 2.5.
often reported,
Image courtesy ABIOMED Inc, Danvers, Massachusetts.
can occur.
www.ccnonline.org
Downloaded from http://ccn.aacnjournals.org/ by guest on June 9, 2014
CriticalCareNurse OnlineNOW e6
can be mechanically induced
when red blood
cells are damaged as they
pass through the
microaxial
pump. When
hemolysis occurs,
hemoglobin level
and hematocrit
decrease, haptoglobin level
decreases, and
plasma levels of
free hemoglobin
increase. If the
hemolysis is
Figure 8 Fluoroscopic image of Impella 2.5 in place in the aorta.
severe, hemogloImage courtesy ABIOMED Inc, Danvers, Massachusetts.
binuria will be
seen; if the
bundle is required for these patients,
hemolysis is sustained, acute kidney
including elevation of the head of
injury will occur.
the bed to decrease the risk of
Patients on Impella 2.5 support
ventilator-associated pneumonia, as
who may require interrogation of a
well as deep venous thrombosis and
permanent pacemaker or implantable
peptic ulcer prophylaxis. Regular
cardioverter defibrillator present an
repositioning of patients and assessinteresting situation. In order for
ment of their skin are necessary to
the interrogator to connect with the
prevent skin breakdown.
permanent pacemaker or implantable
The patient with an Impella 2.5
cardioverter defibrillator, the Impella
is at risk of limb ischemia because of
console must be turned off for a few
the large size of the device. The arteseconds while the signal is estabrial access site must be assessed reglished. As soon as the signal has
ularly for bleeding and development
been established, Impella support
of a hematoma. Distal pulses of the
is immediately restarted.
affected leg should be assessed at least
hourly. The use of anticoagulation is
Impella 2.5 Console
required, and bleeding may develop
Management
in some patients. The partial thromThe recommended maximum
boplastin time should be monitored
performance level for continuous
every 4 to 8 hours and maintained
use is P8. At P8, the flow rate is 1.9
at about 45 to 55 seconds, unless a
to 2.6 L/min and the motor is turnhigher partial thromboplastin time
ing at 50000 revolutions per minute.
is required for some other reason.
When activated, the console is silent.
Hemolysis can occur in patients
No sound other than alarms is audiwho are on the Impella 2.5. Hemolysis
ble during Impella support, unlike
e7 CriticalCareNurse OnlineNOW
the sound heard with an IABP. Ten
different performance levels ranging from P0 to P9 are available
(Table 5). The performance level
determines the flow rate and the
number of revolutions per minute.
As the performance level increases,
the flow rate and number of revolutions per minute increase. At maximum performance (P9), the pump
rotates at 50000 revolutions per
minute and delivers a flow rate of
2.1 to 2.6 L/min. P9 can be activated
only for 5-minute intervals when
the Impella 2.5 is in use.
Several parameters require regular monitoring for the duration of
therapy. Regular documentation is
essential, and review of trends is
useful when troubleshooting. Parameters to assess regularly include
placement signal, placement monitoring (pump position), dual signal,
purge pressure, motor current, and
speed (Table 6).
Alarms
Several console alarms may
require nursing intervention
(Table 7). The most common include
suction, low purge pressure, and
high purge pressure alarms. Information about the alarm can be seen
on the console screen. An audible
alarm also will sound. Suction
alarms can occur if the performance
level is too high for the patient; for
example, in a patient who is hypovolemic or if the device is emptying
the ventricle. A low purge pressure
alarm indicates that the purge pressure to the Impella motor has
decreased below 300 mm Hg. A low
purge pressure can allow blood to
enter the motor and damage the
motor, rendering the device inoperable. Low purge pressures require
www.ccnonline.org
Downloaded from http://ccn.aacnjournals.org/ by guest on June 9, 2014
Table 3
Potential complications of Impella 2.5 support
Complication
How it could develop
How to recognize
Bleeding, vascular injury,
ischemia of affected
extremity
Lack of hemostasis at
arterial access site
Large sheath (13F) can
obstruct/impede flow to
affected extremity
Direct arterial damage can
occur during device
placement
Loss of pulses in affected
foot/leg
Pain, pallor, coolness,
paresthesia, and/or paralysis of affected foot/leg
Decreased hemoglobin and
hematocrit
Assess and monitor pulses, skin color,
temperature, and capillary refill hourly
Notify physician of changes to the affected
extremity
Monitor results of laboratory tests
Administer blood and blood products as
ordered
Hemolysis
Rupture of red blood cells
by impellar blades/high
flow causing hemoglobin
to leak into plasma
Laboratory specimens are
hemolysed
Urine is red, burgundy,
brown because of red
blood cells in the urine
Decreased haptoglobin levels, elevated plasma levels of free hemoglobin
Hemolysis is most pronounced when
Impella is not positioned well; notify
physician of hemolysis
Anticipate echocardiography to assess
repositioning of Impella
Decrease flow levels on Impella when possible
Device migration
Catheter may inadvertently
advance or be withdrawn
with excessive movement, turning
Positioning alarms
Changes in placement
signal parameters
Maintain elevation of head of bed at ≤30°
After placement, note position markings on
catheter shaft and document for reference
each shift
Secure device with tape; secure tubings to
lower leg
Infection, sepsis
Placement of Impella and
other invasive monitoring
catheters
Inflammation, tenderness,
or purulent drainage at
access site
Increased body temperature
Aseptic technique during placement
Sterile dressing change
Daily tubing change
Monitor patient for fever, elevated white
blood cell count
Aortic valve damage (rare)
Trauma during device
placement
Continued heart failure due
to aortic valve damage
Echocardiographic evidence
of aortic insufficiency
Monitor placement signal hourly
Notify physician of Impella position alarms
Device failure (rare)
Defective device
Loss of pump function,
console alarms
Deterioration in patient’s
condition
Monitor and document console parameters
hourly
Respond promptly to console alarms and
trouble-shoot as indicated
Notify Impella coordinator and physician of
ongoing alarms
immediate intervention by a critical
care nurse. A high purge pressure
alarm indicates that the purge pressure is greater than 700 mm Hg and
generally indicates a kink in the
tubing or catheter.
If the device advances too far and
both the inflow and outflow areas are
fully in the left ventricle, the pump
position wrong alarm will occur. On
the placement signal screen, the waveform will show a ventricular, rather
than an aortic, pressure waveform.
How to prevent/manage
The motor current signal will be flattened. The placement monitoring diagram will show the aortic valve
symbols distal to the pump (Figure 9).
The performance level should be
decreased to P2 and the physician
should be notified to reposition the
device by pulling it back slightly to
obtain an aortic waveform. Repositioning is best performed under fluoroscopic guidance, whenever possible.
If the Impella 2.5 is completely
in the aorta, or if the inlet and outlet
areas are in the ventricle and the pressure port is in the aorta, the pump
position alarm will sound. The placement signal will show a normal
appearing aortic waveform with
systolic and diastolic pressures similar to those shown by the patient’s
arterial catheter. The motor current
will be flattened. The placement
monitoring diagram will continuously scroll through 3 different
images because it is not able to differentiate the position of the catheter.
www.ccnonline.org
Downloaded from http://ccn.aacnjournals.org/ by guest on June 9, 2014
CriticalCareNurse OnlineNOW e8
Table 4
Nursing care of patients with an Impella 2.5
Problem
Expected outcomes/goals
Nursing intervention and rationale
Decreased cardiac output
related to decreased cardiac
contractility
With the Impella in place, the
patient will
• be hemodynamically stable,
as evidenced by systolic
blood pressure >90 mm Hg,
heart rate >50/min and
<100/min, cardiac indexa ≥2
• have warm and dry skin
• maintain urine output >30 mL/h
• be alert and oriented
• be free of hemodynamically
compromising arrhythmias
Continuous cardiac monitoring
Measure vital signs and pulmonary artery pressures hourly; notify
physician of changes
Determine cardiac output/cardiac index every 4 hours and with
changes in vasoactive medications; notify physician of changes
Administer and titrate vasoactive medications as ordered
Monitor urine output hourly and notify physician if <30 mL/h
Evaluate for changes in mental status, including confusion, restlessness, and decreased responsiveness
If patient requires cardiopulmonary resuscitation, decrease
Impella performance level to P2 for duration of chest compressions; after chest compressions, obtain chest radiograph or
echocardiogram to assess placement of the Impella
Potential for bleeding related
to device placement and
anticoagulation
The patient will:
• be free of bleeding/hematoma
at the arterial access site
• have a partial thromboplastin
time (PTT) between 45 and
55 seconds
• maintain baseline hemoglobin, hematocrit, and platelet
levels
Assess the arterial access site for bleeding/hematoma hourly
Adjust heparin infusion as needed to maintain PTT parameters;
measure PTT every 6-8 hours while on Impella support
Notify physician of PTT outside of goal range and titrate heparin
infusion as needed
Assess laboratory results, including hemoglobin level, hematocrit, and platelet count
Notify physician of decreases in hemoglobin level, hematocrit, or
platelet count
Potential for limb ischemia
due to device placement
Patient will
• maintain baseline circulation
to affected extremity
Monitor presence and quality of distal pulses in the affected
extremity hourly
Assess sensation and movement of affected extremity
Notify physician of loss of pulses, pallor, pain in leg/foot, loss of
sensation/movement
Potential for hemolysis
related to device placement
Patient will
• maintain integrity of red
blood cells
• maintain urine free of red
blood cells
Monitor laboratory samples for presence of hemolysis
Monitor plasma levels of free hemoglobin and haptoglobin
Monitor urine for changes in color, as hemolysis breaks down
red blood cells, urine becomes red to brown
Administer blood and blood products as ordered
Potential for infection related
to device placement
Patient will
• remain free of signs and
symptoms of infection
Change sterile dressing daily by using strict aseptic technique;
change more frequently if any drainage is present
Remove monitoring catheters as possible
Ensure adequate nutrition to promote healing
Notify physician of elevated body temperature and other signs of
infections, such as redness, tenderness, warmth at the site,
purulent drainage, elevated white blood cell count
Potential for device malfunction/device failure
Patient will
• be free of device failure
Elevate head of bed ≤30°, turn patient carefully to prevent inadvertent pulling on the Impella catheter shaft and/or tubing
Assess and document exposed number of centimeter markings
on the catheter shaft once each shift
Assess and troubleshoot positioning alarms (outlined in Table 7)
Notify physician of suspected suboptimal positioning of device or
device failure immediately
Potential for discomfort related
to pain, anxiety, bed rest
Patient will
• be comfortable
• report decreased anxiety
Administer analgesics as ordered for discomfort
Reposition patient for comfort as needed
Knowledge deficit
Patient/patient’s family will
• verbalize understanding of
plan of care and need for
device
Explain the need for the Impella device in assisting the heart
Help the patient and the patient’s family understand the need for
bed rest, careful repositioning, frequent assessment, and daily
tubing and dressing changes
a Calculated
as cardiac output in liters per minute divided by body surface area in square meters.
e9 CriticalCareNurse OnlineNOW
www.ccnonline.org
Downloaded from http://ccn.aacnjournals.org/ by guest on June 9, 2014
rapid weaning
can be done.
For rapid weanPerformance level Flow rate, L/min Revolutions per minute
ing, the perP0
0.0
0
formance level
P1
0.0-0.5
25 000
is decreased by
P2
0.4-1.0
35 000
1 or 2 levels
P3
0.7-1.3
37 000
every 5 to 15
P4
0.9-1.5
40 000
minutes until
P5
1.2-1.8
43 000
the pump is
P6
1.4-2.0
45 000
set at P2. The
P7
1.6-2.2
47 000
patient’s hemoP8a
1.9-2.5
50 000
dynamic status
P9b
2.1-2.6
51 000
is assessed after
every decrease
a Level P8 is recommended maximum performance for continuous use.
b P9 is used for verification of catheter position only—can also be used to proin performance
vide maximum flow for up to 2 minutes (console will automatically default to P8
level.
P2 is the
after 5 minutes).
lowest performance level that
The performance level should be
can be used while the distal end of
reduced to P2 and the physician
the Impella 2.5 is in the left ventrishould be notified of the need to
cle. At the end of rapid weaning,
reposition the Impella.
the Impella device can then be
If the patient’s ventricular funcremoved as described in the next
tion is very poor, a positioning alarm
section.
can occur. The alarm will read “pump
Patients who have had the device
position unknown due to low pulin longer or who were in unstable
satility.” The Impella console is not
condition during the procedure
able to determine the pump posimay benefit from a slower weaning
tion because the patient’s systolic
process. Slow weaning is accomand diastolic pressures are not very
plished by decreasing the performdifferent. The placement signal will
ance level by 1 or 2 levels every 2 or
show depressed cardiac function,
3 hours. If the patient tolerates this
evidenced by a damped appearing
slow weaning by remaining hemowaveform. The motor current will
dynamically stable while at P2, the
be flattened. The aortic valve symbols
device is then removed.
will not be seen on the placement
In our facility, we often use
monitoring diagram.
transthoracic echocardiography to
aid in the assessment of our patients.
Weaning
With the physician at the bedside,
Weaning from the partial circulatransthoracic echocardiography is
tory support provided by the Impella
performed and the pump’s perform2.5 can be approached in different
ance level is decreased. The physiways. When the device has been in
cian can evaluate left ventricular
only for support during high-risk PCI
size and function and can quickly
and the patient’s condition is stable
assess how well the patient tolerates
after the procedure is completed,
decreases in the performance level.
Table 5
Impella 2.5 performance level and flow rate
Device Removal
When the physician is ready to
discontinue the Impella 2.5 catheter,
the groin dressing should be
removed, the site cleansed with
chloroprep, and the sutures clipped.
Immediately before removal of the
device, decrease the performance
level to P0. The catheter is then
pulled back from the left ventricle
into the ascending aorta and then
completely withdrawn. The arterial
sheath can be left in place to be
removed separately, or the catheter
and the sheath can be removed as a
unit, as is common when removing
an intra-aortic balloon catheter
placed through a sheath.
The Impella 2.5 instructions for
use recommend a 40-minute manual hold to achieve hemostasis at
the arterial access site. We follow
our hospital’s protocol for achieving hemostasis, using either manual
or mechanical compression. Some
facilities may use what is referred
to as a preclose method while the
patient is still in the catheterization
laboratory; that technique uses 2
8F Perclose suture-mediated closure
devices (Abbott Laboratories,
Abbott Park, Illinois). The Impella
2.5 can also be removed in the surgical setting with direct visualization of the common femoral artery.
A cutdown is performed, and the
device is removed by the surgeon.
Arterial repair is done at that time,
and the incision is covered with a
sterile dressing.
Our Experience
To date, we have placed an
Impella 2.5 in about 40 patients.
Our facility has a high-volume
interventional cardiology program
as well as a busy adult and pediatric
www.ccnonline.org
Downloaded from http://ccn.aacnjournals.org/ by guest on June 9, 2014
CriticalCareNurse OnlineNOW e10
Table 6
Console monitoring screens
Parameter
What it means
Placement signal
This is a positioning aid. It evaluates
the position of the device. The pressure
is obtained from the pressure lumen
that ends near the motor. It should
“see” an aortic waveform; however, if
the device is too far in, a ventricular
waveform will be seen.
Motor current
Displays the amount of electrical current that is required to power the motor
of the catheter device. The motor current increases as the flow increases
and decreases as the flow decreases.
It should be a pulsatile waveform.
Purge pressure
Displays the current purge pressure.
This pressure is measured in millimeters mercury (mm Hg).
Speed
Displays the rotations per minute of
the impellar blades.
Flow
Displays the flow that is being aspirated from the left ventricle. This value
can be found in the upper right corner
of all screens.
Screen display
This graphic display shows a
Placement monitoring schematic of the pump position in
relationship to the aortic valve.
Dual signal
Displays 2 waveforms. The top waveform is the motor current and the bottom waveform is the placement signal.
This screen can be useful in advanced
troubleshooting.
cardiovascular surgery service. We
have extensive experience with the
IABP and with surgically placed
VADs, including the Abiomed
AB5000, Thoratec CentriMag, XVE,
and HeartMate II. Our use of the
Impella 2.5 was our first experience
with percutaneously placed partial
circulatory support devices. We
have also placed the Impella 5.0 in
e11 CriticalCareNurse OnlineNOW
3 patients. We have gained much
knowledge since implementing our
Impella program in April 2008.
Based on our experiences, we share
the following recommendations.
1. Assign a point person who
can oversee and coordinate the program. In our facility, this role is filled
by the interventional cardiology
clinical nurse specialist. All patients
with this device are observed by
this clinical nurse specialist during
their hospital stay. Additionally,
patients are observed by the VAD
coordinator.
2. Limit the physicians who
can place and manage the device
and have them proctor one another.
In our facility, physicians who
can place this device are those
who have interventional cardiology and/or cardiac surgery privileges. All cases are also followed
by the cardiac surgeon who oversees our VAD program and a critical care intensivist. We developed
preprinted orders for physicians
to use for patients remaining on
support to ensure consistency in
care (Table 8).
3. Train a core group of nurses
and cardiovascular technologists
from the catheterization laboratory
for initial setup of the console,
catheter preparation, and assisting
with placement of the device. Console and infusion pump setup
requires 2 to 3 minutes to complete.
Our training for staff from the
catheterization laboratory consisted
of a 3-hour session with didactic
and hands-on training. Ongoing
practice is essential to develop and
maintain competency. The Impella
coordinator is present for implants
to assist the catheterization laboratory staff as needed. The VAD coordinators also provide valuable
assistance. We found it helpful for
the first few Impella placements to
be planned, elective placements for
high-risk PCI. This arrangement
allowed ample time for setting up
the console and infusion pump
before the Impella was placed.
4. Develop a nursing protocol
that outlines key strategies in patient
www.ccnonline.org
Downloaded from http://ccn.aacnjournals.org/ by guest on June 9, 2014
Table 7
Impella 2.5 alarm troubleshooting
Alarm
What to do
What it means
Low purge pressure
Purge pressure is less than 300 mm Hg. Correct the purge pressure quickly to prevent damage of the
motor
With low purge pressure, blood can
Assess for leaks or loose connections in the purge system.
enter the motor and damage it.
Increase the purge pressure by delivering a bolus of 1 mL and
increasing the continuous rate on the Braun Vista Pump by 1 mL/h.
If maneuvers to increase the purge pressure to between 300 and
700 mm Hg are not effective within 5 minutes, the Impella may
need to be removed.
High purge pressure
Purge pressure is higher than
700 mm Hg.
Tubing may be kinked.
Concentration of purge fluid may be
too high.
Suction likely
The console has detected pump suction. Reduce the performance level by 2 levels (for example, decrease
from P8 to P6).
The patient may be hypovolemic, and
the pump may be completely empty- Assess hemodynamics and left ventricular filling; correct hypovolemia if present.
ing the left ventricle.
Pump position wrong
Pump outlet is blocked—the pump is
too far in the ventricle and the outlet
may be at the level of the aortic valve.
Reposition pump; wrong pump position
was detected.
Assess and support patient as indicated.
Notify the physician/Impella coordinator.
May assess placement by echocardiography/portable chest
radiography.
Pump most likely needs to be repositioned by the physician.
High motor current value
There are mechanical problems with
the pump. The motor current for the
selected performance level has been
exceeded.
If the motor current continues to increase, the catheter should
be removed.
Look for kinks in the tubing or catheter.
Decrease the flow rate of purge fluid by 1 mL/h on the Braun
Vista Pump. Do not decrease the flow rate to less than 4 mL/h.
May need to decrease the concentration of the purge fluid
(eg, change from 20% dextrose to 10% dextrose).
If the alarm persists for more than 2 hours after the preceding
steps are taken, the device should be removed.
Figure 9 Placement monitoring screen display shows that pump position is wrong.
Image courtesy ABIOMED Inc, Danvers, Massachusetts.
management and a specific flow
sheet (Figure 10) for documentation.
5. Train a core group of critical
care nurses to care for the patient,
monitor the device, change tubings,
and troubleshoot alarms. We provide 1-to-1 staffing for our patients
with an Impella 2.5 until they are
hemodynamically stable. Our training for our cardiac intensive care
unit (CICU) nurses consisted of a
series of three 1-hour sessions,
encompassing a review of pertinent
physiology and hemodynamics,
Impella console management and
troubleshooting, and tubing changes
with hands-on practice and documentation practice. Staff received
1-to-1 mentoring from the Impella
coordinator. Review of patient care
www.ccnonline.org
Downloaded from http://ccn.aacnjournals.org/ by guest on June 9, 2014
CriticalCareNurse OnlineNOW e12
Table 8
Physician orders for placement of Impella 2.5
Transfer to cardiac intensive care unit, continuous cardiac monitoring
See orders for after percutaneous coronary intervention for additional physician orders
Complete bed rest; may turn and reposition patient as needed; do not elevate head of
bed to >30°
Every hour and as needed: assess and document patient’s vital signs, access site,
distal pulses, hemodynamic parameters, urine output, Impella performance level,
flow, placement signal, motor current, pump position, and purge pressure
Perform the following diagnostic tests:
On arrival in unit: complete blood cell count, renal panel, partial thromboplastin time,
plasma free hemoglobin, portable chest radiograph, 12-lead electrocardiogram
Every 8 hours while on Impella support: partial thromboplastin time
In morning: transthoracic echocardiography to assess placement of device
Daily while on Impella support: plasma-free hemoglobin, complete blood cell count,
renal panel
Notify Impella coordinator of changes in patient’s status or concerns regarding Impella
device/Impella console
Notify physician if partial thromboplastin time <45 seconds; goal for partial thromboplastin time is 45-55 seconds
Daily at 3 PM:
Change purge fluid/tubing system by using 500 mL dextrose 20% in water with
heparin 25 000 units
Change arterial fluid/tubing system, using 500 mL normal saline with heparin 1000 units
Sterile dressing change
management strategies, console
troubleshooting, and fluid/tubing
setup has also been added to our
annual VAD skills fair (Table 9).
6. Work with pharmacy and nursing staff to develop a standardized
time for fluid and tubing changes.
We found performing such changes
at a consistent time to be very helpful. This arrangement ensured that
new purge fluid was ready when
needed and that the nurses had
more staffing resources to assist with
the tubing change. The pharmacy
prepares the heparinized 20% glucose
purge solution and sends it to the
unit before our standard change time
of 3 PM daily. We have 2 nurses at the
bedside for the tubing change. The
Impella coordinator is present to
assist with tubing changes as needed
by the nursing staff.
7. Include the cardiovascular surgery staff and perfusion staff in the
e13 CriticalCareNurse OnlineNOW
initial training. Patients with an
Impella may go to the cardiovascular
operating room for bypass surgery
or valve repair/replacement. Coordination with the perfusionist is
essential when patients are being
placed on cardiopulmonary bypass.
As the patient goes on cardiopulmonary bypass, the performance level
of the Impella must be decreased.
When the patient is coming off of
cardiopulmonary bypass, the performance level of the Impella pump,
if the pump remains in place, must
be increased to provide adequate
flow to the patient. In some facilities, the perfusionist manages both
the cardiopulmonary bypass and
the Impella. In our facility, we have
a trained CICU nurse managing the
Impella while the patient is in the
cardiovascular operating room.
8. Partner with industry. Abiomed
provides strong clinical support as
well as excellent print and Web-based
educational materials. A console
simulator is available that can be used
to practice troubleshooting. Abiomed also provides assistance with
troubleshooting via 24-hour-a-day,
7-day-a-week telephone support.
Summary
The Impella 2.5 device is an
alternative to an IABP that may be
beneficial in some patients who
need hemodynamic support. It is
useful in patients undergoing highrisk PCIs. The Impella 2.5 should
not be used in patients with aortic
valve disease or known left ventricular thrombus. Potential complications include bleeding, vascular
injury, hemolysis, infection, sepsis,
and device malfunction or failure.
Nursing care is directed toward
support of critically ill patients,
including frequent hemodynamic
assessment, titration of vasoactive
medications as indicated, Impella
console troubleshooting, and monitoring for potential complications.
A multidisciplinary approach to
establishing a program for the
Impella is useful in ensuring competency and good outcomes for
patients. The following 3 case studies demonstrate the successful use
of Impella 2.5 support during highrisk PCIs at our facility.
Case Study 1
A 71-year-old man was referred
to our facility for saphenous vein
bypass graft (SVG), a high-risk PCI.
Diagnostic cardiac catheterization
and coronary angiography performed at the referring facility
showed severe triple vessel coronary
disease and high-grade lesions in 2
SVGs. He had a history of coronary
www.ccnonline.org
Downloaded from http://ccn.aacnjournals.org/ by guest on June 9, 2014
Date: ___________________________
ABIOMED 1-800-422-8666
Time:
Infusion Rate (mL)
(4-12 mL)
Flow L/min:
P-Perf Level:
Placement Signal:
Pump Position:
Dual Signal:
Purge Pressure:
(300-700-mmHg)
Motor Current:
Speed RPM:
Power (AC / Batt):
Groin Check (✓)
Pulse Check (✓)
Initials
Patient Identification
Document hourly and PRN
RN SIGNATURE
Every 8 hour labs: creatinie, ABGs with ionized calcium, PTT
Notify physician if PTT < 45 seconds
Ventricular Assist Device
Flowsheet for Impella 2.5
21781 (5/13/09)
FLOWSHEET
Pump Serial Number:
Access Site: Right / Left Femoral Artery
# of exposed Hash Marks:
Last sterile dressing change:
Last tubing change:
Use back of flow sheet for additional Impella
documentation id needed
Figure 10 Impella 2.5 flowsheet.
Abbreviations: ABGs, arterial blood gas analysis; AC, alternating current; Batt, battery; P-perf, pump performance level; PRN, as needed; PTT, partial thromboplastin
time; RN, registered nurse; RPM, revolutions per minute.
Image courtesy Sutter Medical Center, Sacramento, California.
artery bypass grafting surgery several
years prior as well as heart failure.
His estimated ejection fraction was
markedly decreased at 20% (normal,
55%-70%) on a recent echocardiogram. He was experiencing progression of his anginal symptoms, and
his functional capacity was poor.
He declined repeat bypass surgery.
After careful evaluation and optimization of pharmacological therapy for heart failure, the decision
was made to proceed with high-risk
PCI of the SVG to the left anterior
descending (LAD) artery with an
Impella 2.5 used to provide partial
circulatory support during the PCI.
The patient was brought to the
catheterization laboratory and prepared for the procedure. On arrival,
his blood pressure was 151/88 mm
Hg with a heart rate of 66/min.
Sheaths were placed in the right
femoral vein, the right femoral
artery, and the left femoral artery.
An SvO2 pulmonary artery catheter
showed that the patient’s baseline
pulmonary artery pressures were
markedly elevated at 69/40-47 mm
Hg (normal: 20-30/8-12 mm Hg;
mean, 25 mm Hg). Heparin 7000
units was administered intravenously
for anticoagulation. When the activated clotting time was higher than
250 seconds, the Impella 2.5 was
advanced into position via the left
common femoral artery and placed
across the aortic valve into the left
ventricle. The catheter device was
connected to the Impella console and
support was initiated. The performance level was increased from P0 to
a maximum of P8 in a matter of minutes. At P8, the flow was 2.5 L/min
and the patient’s cardiac index was
2.58 (normal, 2.5-4).
The PCI procedure of the LAD
SVG was then started. The SVG was
aspirated before a distal protection
device was placed. One bare metal
stent (not a drug eluting stent) was
www.ccnonline.org
Downloaded from http://ccn.aacnjournals.org/ by guest on June 9, 2014
CriticalCareNurse OnlineNOW e14
Table 9
Impella competency checklist for nurses in the cardiac intensive care
unit: critical elements for managing patients with an Impella 2.5
Lists resources for assistance (trained peers, clinical nurse specialists, ventricular assist
device coordinators, ABIOMED toll-free phone line, reference binder on Impella cart)
Demonstrates use of Impella console:
Verifies placement signal
Changes performance level/pump speed
Verifies purge pressure
Demonstrates troubleshooting of Impella components:
Power supply
Common alarms (low and high purge pressure, suction)
Braun Vista infusion pump
discharged 2 days later taking
appropriate medications for after
PCI and to treat heart failure. Six
weeks later, the patient was pain
free with no complaints of dyspnea.
Transthoracic echocardiography
showed increased contractility, and
the ejection fraction was 40%. At
follow-up 12 months later, the patient
remained symptom-free with a normal ejection fraction of 55%.
Changes arterial flush fluid and tubing per checklist
Changes purge fluid and tubing per checklist
Case Study 2
Describes required patient care
Assessment/reassessment of findings, including hemodynamic profile
Performs sterile dressing change
States potential complications and how to assess/prevent them
Reviews orders, communicates changes to cardiology/cardiothoracic surgeon
If cardiopulmonary resuscitation needed, decrease performance level to P2, and
initiate Advanced Cardiac Life Support protocols
A 74-year-old man was transferred to our facility after sustaining a non–ST-segment elevation
myocardial infarction. He had a
long history of diabetes and had
undergone coronary artery bypass
surgery 20 years prior. Diagnostic
cardiac catheterization showed
severe triple vessel disease as well
as severe diffuse distal disease of his
left internal mammary artery
(LIMA) graft, his only remaining
patent graft. He had severe mitral
regurgitation. His ventricular function was poor with a calculated
ejection fraction of 20%. His left
ventricular end-diastolic pressure
was markedly elevated at 40 mm Hg
(normal, 5-12 mm Hg), and his cardiac index was reduced at 1.98. He
was evaluated by our cardiothoracic
surgery team and was deemed an
extremely poor candidate for surgery. After a family conference that
included the patient, the decision
was made to proceed with high-risk
PCI of the LIMA graft, using the
Impella 2.5 for hemodynamic support during the procedure.
He returned to the catheterization
laboratory the next day for coronary intervention. On arrival, his
blood pressure was 105/66 mm Hg
with a heart rate of 64/min. Sheaths
placed in the SVG to the LAD. During this time, transient no-reflow
developed. No reflow is a phenomenon in PCI that can cause severe
hemodynamic compromise because
myocardial perfusion through a
given segment of the coronary circulation is inadequate, yet no angiographic evidence of mechanical
obstruction of the vessel is apparent.15
The patient’s pulmonary artery pressures increased to 93/40-58 mm Hg
and the cardiac index decreased to
2.2. Despite the no-reflow, the arterial pressure, heart rate, and cardiac
rhythm remained stable, and the
patient had no complaints of shortness of breath or chest discomfort.
Adequate blood flow was reestablished after the intracoronary administration of 500 µg nitroglycerin.
Because the patient was tolerating
the procedure well after this, the
physician decided to stent the second
diseased SVG. With the Impella continuing at maximum flow of 2.5 L,
2 bare metal stents were deployed
e15 CriticalCareNurse OnlineNOW
in the SVG to the posterior lateral
branch. Pulmonary artery pressures
remained elevated after this stent
was placed, and the patient was
given furosemide and nitroglycerin
to decrease preload and increase
diuresis. Just before the patient’s
return to the CICU, the pulmonary
artery pressure decreased to 70/4148 mm Hg and the cardiac index
was 2.69.
The patient was weaned from
the Impella device, the device was
removed in the catheterization laboratory, and the venous and arterial
sheaths were secured in place. The
total duration of Impella support
was slightly less than 2 hours. The
patient was transferred to the CICU
for continued monitoring. Four hours
later, after the activated clotting time
was less than 150 seconds, the venous
and arterial sheaths were removed
and hemostasis was achieved after
40 minutes of manual compression.
The patient’s remaining hospital
course was uneventful and he was
www.ccnonline.org
Downloaded from http://ccn.aacnjournals.org/ by guest on June 9, 2014
were placed in the right femoral
vein, the right femoral artery, and
the left femoral artery. Heparin
9000 units was administered intravenously for anticoagulation, and
the Impella 2.5 was advanced into
position in the left femoral artery.
Support was established at P8. The
coronary guidewire was advanced
through the LIMA graft to the distal LAD. Three sequential stents
were placed in the area of disease.
The patient’s vital signs and cardiac
rhythm remained stable throughout
the procedure. The patient was rapidly weaned from the Impella, which
was removed in the catheterization
laboratory. The 13F arterial sheath
was sutured in placed for removal
4 hours later after the patient was
returned to the CICU. He was discharged home 2 days later.
Case Study 3
A 63-year-old woman was
admitted to our facility with an
acute anteroseptal myocardial
infarction. She was treated with
fibrinolytic therapy but continued
to have chest pain. She had a history of hypertension complicated
by end-stage renal disease and was
receiving dialysis treatments 3
times per week. She was taken to
the catheterization laboratory,
where she was found to have a significant obstruction of the left main
coronary artery complicated by
plaque rupture. She was evaluated
by our cardiac surgery team, who
thought that she was a very highrisk candidate for surgery based on
the recent fibrinolytic therapy, her
renal failure, and the remote history of stroke. She was transferred
to the CICU and supportive medical therapy was initiated.
She returned to the catheterization laboratory 3 days later for highrisk PCI of the left main coronary
artery. On arrival, her blood pressure was 127/72 mm Hg, and her
heart rate was 54/min. Sheaths
were placed in the right femoral
vein, the right femoral artery, and
the left femoral artery. Bivalirudin
was administered for anticoagulation, and the Impella 2.5 was
advanced into position in the left
femoral artery. Support was established at P8.
The left main lesion was crossed,
and one stent was deployed at the
lesion. During stent deployment,
the patient had severe chest pain
and showed ST-segment elevation
in the anterior leads. Despite these
changes, her blood pressure and
cardiac rhythm remained stable.
Intravascular ultrasound was performed to confirm optimal stent
placement. At the end of the procedure, she was symptom free, and
she was rapidly weaned from the
Impella and the device was removed.
The 13F arterial sheath was sutured
in placed for removal 2 hours later,
after the patient had returned to the
CICU. She had no further chest pain
during her hospitalization and was
discharged home in stable condition 3 days later. CCN
3. Lee MS, Makkar RR. Percutaneous left ventricular support devices. Cardiol Clin.
2006;24(2):265-275.
4. Kale P, Fang JC. Devices in acute heart failure.
Crit Care Med. 2008;36(suppl):S121-S128.
5. Seyfarth M, Sibbing D, Bauer I, et al. A randomized clinical trial to evaluate the safety
and efficacy of a percutaneous left ventricular assist device versus intra-aortic balloon
pumping for treatment of cardiogenic shock
caused by myocardial infarction. J Am Coll
Cardiol. 2008;52:1584-1588.
6. Remmelink M, Sjauw KD, Henriques JP, et
al. Effects of left ventricular unloading by
Impella Recover LP 2.5 on coronary hemodynamics. Catheter Cardiovasc Interv. 2007;
70(4):532-537.
7. Reid MB, Cottrell D. Nursing care of patients
receiving intra-aortic balloon counterpulsation. Crit Care Nurse. 2005;25(5):40-49.
8. Weber DM, Raess DH, Henriques JPS, Siess T.
Principles of Impella cardiac support. http://
bmctoday.net/citoday/2009/09/supplement
/article.asp?f=0909_supp_01.php.
Accessed November 16, 2010.
9. Henriques JPS, Remmelink M, Baan J, et al.
Safety and feasibility of elective high-risk
percutaneous coronary intervention procedures with left ventricular support of the
Impella Recover LP 2.5. Am J Cardiol. 2006;
97(7):990-992.
10. Dixon SR, Henriques JPS, Mauri L, et al. A
prospective feasibility trial investigating the
use of the Impella 2.5 system in patients
undergoing high-risk percutaneous coronary intervention (the PROTECT I trial):
Initial U.S. experience. J Am Coll Cardiol.
2009;2:91-96.
11. Burzotta F, Paloscia L, Trani C, et al. Feasibility and long-term safety of elective
Impella-assisted high-risk percutaneous
coronary intervention: a pilot two-centre
study. J Cardiovasc Med. 2008;9:1004-1010.
12. Ferreiro JL, Gomez-Hospital JA, Cequier
AR, et al. Use of Impella Recover LP 2.5 in
elective high risk percutaneous coronary
intervention [published online ahead of
print September 2, 2009]. Int J Cardiol.
doi:10.1016/j.ijcard.2009.08.003.
13. Stahl MA, Richards NM. Update on ventricular assist device technology. AACN Adv Crit
Care. 2009;20(1):26-34.
14. Impella: Instructions for Use for the Impella
2.5 Circulatory Support System. Danvers, MA:
Abiomed, Inc; 2007.
15. Eeckhout E, Kern MJ. The coronary no-reflow
phenomenon: a review of mechanisms and
therapies. Eur Heart J. 2001;22:729-739.
Now that you’ve read the article, create or contribute
to an online discussion about this topic using eLetters.
Just visit www.ccnonline.org and click “Respond to
This Article” in either the full-text or PDF view of
the article.
Financial Disclosures
Brenda McCulloch is a member of the Abiomed
Administrative Advisory Board.
References
1. Vegas A. Assisting the failing heart. Anesthesiol Clin. 2008;26:539-564.
2. Sarkar K, Kini AS. Percutaneous left ventricular support devices. Cardiol Clin.
2010;28:169-184.
www.ccnonline.org
Downloaded from http://ccn.aacnjournals.org/ by guest on June 9, 2014
CriticalCareNurse OnlineNOW e16
Downloaded from http://ccn.aacnjournals.org/ by guest on June 9, 2014