PERCUTANEOUS AXIAL PUMPS (LV IMPELLA) by Nick Mark MD &

Tim Balthazar MD & Jeff Scott DO ONE

onepagericu.com
@nickmmark
Link to the
most current
PRINCIPLE: version →
A percutaneous axial flow pump that uses an impeller to move blood from the LV
UNASSISTED @timbalthazar
to the proximal aorta. This augments aortic and coronary pressures. IMPELLA (partial support; P3) AORTIC
VALVE
• Forward flow depends on the model used (2.5, CP, LD, and 5.5) and the IMPELLA (full support; P9) CLOSES Pressure sensor
Program Setting. A purge fluid is added to avoid RBCs being drawn into the LVSP = Systolic BP measures aortic
motor housing. AORTIC pressure
VALVE
• An Impella can provide more hemodynamic support than IABP. It can either be

LV pressure
OPENS
used for support during high-risk PCI or for hemodynamic support in ICU
patients with cardiogenic shock. It can also be a vent in peripheral VA ECMO
PHYSIOLOGY:
Physiologically, an Impella functions as a temporary percutaneous LVAD (see
LVAD OnePager), that continuously unloads the LV. This both reduces the native LVEDP

CO (reducing cardiac work & myocardial O2 consumption) and provides

additional CO via the pump. This provides higher CO with lower cardiac work.
Impella is preload dependent & afterload sensitive. Unlike IABP, Impella does LV volume
not require EKG/pressure triggering so it is more tolerant of arrythmias. By continuously unloading the LV, an Impella Impeller pump is
reduces cardiac work. The degree of ventricular placed across the
PLACEMENT: offloading depends on the level of support. Aortic Valve; draws
Proper placement is essential. The device is typically placed under Fluoroscopic
blood out of the LV
guidance ± TEE. POCUS/TTE are often used to verify placement. CXR can provide CONTRA-INDICATIONS:
some info but does not show rotational malposition. Because the pump can become • Severe AS/AI (unable to• Prosthetic Ao valve
malpositioned, understanding &interpreting placement signals is necessary: pass catheter) • Severe vascular disease
MOTOR CURRENT • LV thrombus (unable to place catheter)
Sheath side port can
D5W
PULSATILE NON-PULSATILE PURGE SOLUTION
Dextrose 5%
solution USP
1000mL
be used for blood
A continuous infusion prevents blood from
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draws
entering the pump motor housing. Dextrose
consequat. Duis aute irure

LOW FLOW
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SUCTION ALARM
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ALARM
est laborum.

solutions may contain Heparin or bicarbonate as

DIASTOLIC CONTINUOUS AORTIC VENTRICULAR CARDIAC additives. The goal is to achieve sufficient Purge
NORMAL
SUCTION SUCTION DISPLACEMENT DISPLACEMENT ARREST Pressure to prevent RBCs entry. Can adjust the Sheath sleeve
purge fluid and purge flow rate to achieve this. allows sterile
repositioning
PROGRAM
Ao Program level determines how fast the
impeller rotates (RPMs), which is proportional Placement Signal MUTE
LV to flow. Higher ”P level” corresponds to greater Ao 94/60mmHg
• LVEDP <-40mmHg • LVEDP<-40mmhg • normal Ao wave • wide swings in Ao •lack of pulsatility in hemodynamic support. LV 99/3 mmHg FLOW

• consider lowpreload •Ao&LV tracings separated; • flat motor signal pressure(LVpattern) both motor signal & Motor Current P8
considermalrotation/position
• flatmotorsignal Ao pressure tracings PLACEMENT SIGNALS
There are two pressure waveforms used as 584/496 mA DISPLAY

COMPLICATIONS: placement signals. The Ao pressure is optically Im pella Flow Purge System PURGE

Bleeding (33%) frequent complication at insertion site. More common if heparin used transduced at the outflow (Ao) positions, the inlet Cardiac Output 6.0 L/min
5.0

v1.0 (2023-05-29) CC BY-SA 3.0

as purge solution (there is also a risk of HIT); consider using bicarbonate or dextrose. pressure (LV) is not measured but is calculated
L/min
Purge Flow
Purge Pressure
Cardiac Power
Output 1.0 watts MENU

Hemolysis (8%) may occur due to malpositioning or insufficient purge flow. Plasma using the motor current and Ao pressures.
free hemoglobin >40 mg/dL is most specific test. Reposition & ensure sufficient preload
Severe cases can be treated with plasmapheresis or other therapies. MOTOR CURRENT
Limb ischemia – Obstruction of the femoral artery due to cannula without a re- Motor current is proportional to pump torque
prefusion canula (like ECMO); use NIR sensors on extremities to hasten diagnosis. and should increase with greater support (e.g.
Suction events – inadequate LV filling or misplacement can cause suction to collapse higher P-level). In patients with any native
the LV. This limits flow and can be arrhythmogenic; assess placement. ventricular function, the motor current varies Calculate Cardiac Output estimates
Cardiac Arrest – change to P2 (recommended) however can use higher program if
during the cardiac cycle. the combined native and pump CO
confident about placement (see Cardiac Arrest on MCS OnePager)