Impella Education, Insertion, Patient Management, Right Heart Failure
Impella® Skills Video: Impella RP® Insertion
This Impella skills video demonstrates insertion of the Impella RP. The video reviews the components in the Impella RP box and presents a simplified version of the technique, highlighting the steps of the procedure, which are as follows:
- Obtain access to the femoral vein (right femoral vein is preferred).
- Insert a 5Fr to 8Fr introducer over the provided 0.035” stiff guidewire to predilate the vessel.
- Remove the 5Fr to 8Fr introducer over the 0.035" stiff guidewire.
- Sequentially insert the 8Fr, 12Fr, 16Fr and 20Fr dilators.
- Remove the 20Fr dilator and insert the 23Fr introducer with dilator, holding the shaft of the introducer while advancing it into the vein.
- Administer heparin.
- Once the ACT is at least 250 seconds, remove the 23Fr dilator and flush the introducer.
- Insert a flow-directed catheter into the 23Fr introducer and direct it into the left (preferred) or right pulmonary artery (PA).
- Form a curve or bend on the provided 0.027” x 260 cm placement guidewire and insert it into the flow-directed catheter.
- Advance the placement guidewire into the pulmonary artery, avoiding over-insertion to the most distal pulmonary artery.
- Remove the flow-directed catheter and backload the Impella RP catheter over the 0.027” placement guidewire.
- Flush the introducer just prior to Impella insertion.
- Advance the catheter through the hemostatic valve into the 23Fr introducer and along the placement guidewire using a fixed wire technique.
- Once the pressure sensor exits the sheath in the inferior vena cava (IVC), perform a manual zero of the sensor by pressing the ZERO SENSOR soft button on the Automated Impella Controller™ (AIC).
- Follow the catheter under fluoroscopy and rotate the catheter as it enters the right ventricle to direct the cannula tip upward and across the pulmonary valve.
- Position the outlet area of the cannula approximately 2-to-4 centimeters above the pulmonary valve. The pigtail should preferentially deflect the left PA, although the right PA may be acceptable.
- Confirm placement of the inlet area in the inferior vena cava at the level of the diaphragm.
- Under fluoroscopy, slowly remove the 0.027” placement guidewire ensuring that the outflow of the pump does not pull back.
- Press the START IMPELLA soft button on the AIC and select performance level P-2 to initiate support.
- Confirm the guidewire has been removed.
- Select YES to start the pump.
- Gradually increase the performance level to achieve optimal flow and hemodynamic support.
- Prior to transferring the patient to the ICU, remove the peel-away sheath and replace it with a repositioning sheath as described in steps below.
- Flush the sidearm of the repositioning sheath located on the catheter shaft.
- Place a dead-end cap on the sidearm of the repositioning sheath to prevent further usage.
- Place a deep mattress suture at the venotomy site, but DO NOT secure it down yet. Abiomed recommends using a 0 or 2 “0” silk on a CT-1 needle.
- While monitoring position of the Impella RP under fluoroscopy, completely remove the 23Fr peel-away introducer from the body while applying manual pressure just above the puncture site to control hemostasis.
- Grasp the two wings of the peel-away introducer and bend back until the valve assembly comes apart. Continue to peel away the introducer until it is completely separated from the catheter shaft.
- Slide the repositioning sheath into the femoral vein so that the yellow hub is at skin level.
- Tie down the mattress suture. Light manual pressure may be needed for hemostasis while securing the mattress suture.
- Maintain manual pressure for an additional 10 to 15 minutes or until hemostasis is achieved.
- Attach the anticontamination sleeve to the yellow hub of the repositioning sheath.
- Lock the anchoring ring in place by turning it clockwise.
- Carefully extend the anticontamination sleeve to maximum length and secure the end closest to the blue Impella plug by tightening the anchoring ring.