Insertion, Surgical Applications
Impella LD® Surgical Insertion
Erik Beyer, MD, shows a case involving surgical insertion of the Impella LD heart pump in a 45-year-old patient following a myocardial infarction. The patient had occluded circumflex and right coronary arteries. Before insertion of the Impella LD, an Impella CP® heart pump was placed in the right common femoral artery and the occlusions were opened with angioplasty.
The next day the patient went to the OR. The patient was placed on cardiopulmonary bypass and the Impella CP was pulled back. Following three-vessel coronary bypass, Impella LD was inserted. “LD,” Dr. Beyer explains, stands for left direct insertion, referring to Impella LD being inserted directly through the aorta through a Hemashield graft.
Dr. Beyer describes the Impella LD insertion process beginning with placement of the 10 mm Hemashield graft. The Impella LD incision template is used to ensure proper placement of the graft on the ascending aorta 7 cm above the aortic annulus. A side-biting clamp is applied to the ascending aorta and an aortotomy performed. The Hemashield graft is then sutured to the aortotomy, and a gel weave on the graft ensures hemostasis at the anastomosis.
Dr. Beyer then explains that the next step involves identifying a second intercostal space inside the chest wall. An incision is made in this area and the Hemashield graft is brought through the second intercostal space and out through the skin incision.
Next, Dr. Beyer describes the components of the Impella LD, identifying the inflow, outflow, and two preloaded 9 mm sponge plugs. He explains that the tip of Impella LD should be placed approximately 3.5 cm below the aortic valve, allowing blood to flow through the device.
Dr. Beyer then shows the Impella LD being inserted into the Hemashield graft, followed by the sponge plug, which is tied with a silk suture for hemostasis. The clamp is removed and the graft is manipulated so that the tip of the Impella LD is directed toward the ascending aorta and aortic valve. The soft clamp is applied to the Hemashield graft once the Impella LD is in a good position. The graft is then cut to the skin and the sponge plugs tied for hemostasis.
In this case, echocardiography showed that the Impella LD was well placed 3.7 cm below aortic valve. The patient came off cardiopulmonary bypass support and Impella was run at P-8, delivering approximately 4.5 L/min of blood to the patient. The patient was extubated three days later and Impella LD was removed on post-op day 14.