Algorithms, Patient Management
Best Practices for Patients Supported with Impella® (Part 6): Impella Weaning and Escalation
Behnam Tehrani, MD, FSCAI, highlights key considerations for escalating or weaning Impella® support in this sixth and final video of the Best Practices for Patients Supported with Impella series.
Dr. Tehrani identifies several key elements to consider for weaning or escalation, including cardiac output, cardiac power output, signs of end-organ perfusion, urinary output, LFTs, lactate, and pressor requirements. He presents an algorithm that considers CPO, RV dysfunction, and hypoxemia as key determinants in assessing of whether to wean the patient from Impella support or escalate to RV support, Impella 5.0®, or a durable LVAD.
If the patient is ready to be weaned from Impella support, Dr. Tehrani offers the following steps for weaning:
- To initiate weaning, reduce P level in 2 level increments (eg, P-8 to P-6 to P-4) as hemodynamics tolerate.
- Keep Impella at P-2 until you are ready to explant the device from the left ventricle.
- Once hemodynamics allow—CVP~10-12, CI>2—pull the catheter from the left ventricle into the aorta at P-2.
- Check ACT and remove Impella when ACT<150-160. (May pre-close in cath lab.)
- Disconnect the device from the Automated Impella Controller™ (AIC).
- Apply manual compression for about 40 minutes.
In conclusion, Dr. Tehrani offers this advice for institutions to follow. “Whatever you do at your institution, just make sure it’s standardized. Make sure it is something that everybody understands, and everybody is cognizant of. And just make sure that it’s followed. And ultimately, review all your cases. The way you will move the standard of care forward, and move the needle, is to not only have low variation in care, but always to review the cases and make sure that you’ve done everything well.”
Dr. Tehrani also highlights that the Abiomed Clinical Support Center (CSC) team is available 24/7 to provide support from pre-implant assessment through daily patient management, providing best practices and troubleshooting guidance for all aspects of device and patient management.