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:

  1. Obtain access to the femoral vein (right femoral vein is preferred).
  2. Insert a 5Fr to 8Fr introducer over the provided 0.035” stiff guidewire to predilate the vessel.
  3. Remove the 5Fr to 8Fr introducer over the 0.035" stiff guidewire.
  4. Sequentially insert the 8Fr, 12Fr, 16Fr and 20Fr dilators.
  5. Remove the 20Fr dilator and insert the 23Fr introducer with dilator, holding the shaft of the introducer while advancing it into the vein.
  6. Administer heparin. 
  7. Once the ACT is at least 250 seconds, remove the 23Fr dilator and flush the introducer.
  8. Insert a flow-directed catheter into the 23Fr introducer and direct it into the left (preferred) or right pulmonary artery (PA).
  9. Form a curve or bend on the provided 0.027” x 260 cm placement guidewire and insert it into the flow-directed catheter. 
  10. Advance the placement guidewire into the pulmonary artery, avoiding over-insertion to the most distal pulmonary artery.
  11. Remove the flow-directed catheter and backload the Impella RP catheter over the 0.027” placement guidewire.
  12. Flush the introducer just prior to Impella insertion.
  13. Advance the catheter through the hemostatic valve into the 23Fr introducer and along the placement guidewire using a fixed wire technique.
  14. 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).
  15. 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.
  16. 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.
  17. Confirm placement of the inlet area in the inferior vena cava at the level of the diaphragm.
  18. Under fluoroscopy, slowly remove the 0.027” placement guidewire ensuring that the outflow of the pump does not pull back.
  19. Press the START IMPELLA soft button on the AIC and select performance level P-2 to initiate support.
  20. Confirm the guidewire has been removed. 
  21. Select YES to start the pump.
  22. Gradually increase the performance level to achieve optimal flow and hemodynamic support.
  23. 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.
  24. Flush the sidearm of the repositioning sheath located on the catheter shaft.
  25. Place a dead-end cap on the sidearm of the repositioning sheath to prevent further usage.
  26. 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.
  27. 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.
  28. 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.
  29. Slide the repositioning sheath into the femoral vein so that the yellow hub is at skin level.
  30. Tie down the mattress suture. Light manual pressure may be needed for hemostasis while securing the mattress suture.
  31. Maintain manual pressure for an additional 10 to 15 minutes or until hemostasis is achieved.
  32. Attach the anticontamination sleeve to the yellow hub of the repositioning sheath.
  33. Lock the anchoring ring in place by turning it clockwise.
  34. Carefully extend the anticontamination sleeve to maximum length and secure the end closest to the blue Impella plug by tightening the anchoring ring.

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IMP-2106