Access & Closure, Anticoagulation, Right Heart Failure

Jerome Crowley, MD: Early Experience With Impella RP Flex™ with SmartAssist®


“Our early experience with the device is that its very easy to place,” explains Jerome Crowley, MD, MPH, referring to internal jugular (IJ) placement of the Impella RP Flex™. Dr. Crowley is ECMO director and cardiac anesthesiologist at Massachusetts General Hospital. In this interview with Bobbi Bogaev Chapman, MD, he describes his early experience with Impella RP Flex™.

Dr. Crowley explains that placing the internal jugular sheath is straightforward. While he usually places the RP Flex in the operating room with both fluoroscopic and transesophageal echocardiography (TEE) guidance to confirm position, he notes, “I certainly have done plenty with just fluoroscopy and the position stability has not been a problem in the ICU.”

“I think the biggest benefit of the RP Flex is that its easier to deliver [than the Impella RP® with SmartAssist®]. I think it’s more straightforward and placement is more forgiving for tortous anatomy.” He highlights that the ability to place it supradiaphragmatic and to enable patients to be ambulatory is helpful for patients bridging to durable LVADs.

Dr. Crowley explains that when selecting patients for right ventricular support, it is important to have exit pathways in mind. He also emphasizes, “Just like almost everything else you see in temporary circulatory support, earlier is better… And one of the real benefits we have seen with our early experience of right ventricular assist devices like the RP Flex, is that we can place it early and avoid the need for emergent venoarterial ECMO, which has its own complications and limitations in patient mobility.”

Dr. Crowley discusses anticoagulation strategies in the surgical patient population, noting, “our purge solutions for all our percutaneous pumps are all now made with bicarb to avoid any heparin variation there.” He also highlights the potential benefits of switching systemic anticoagulation from heparin to bivalrudin in some patients. 

Dr. Crowley describes his experience with his first RP Flex patient who was on biventricular (“Bipella”) support. He also shares insights on venous site access management and the internal jugular approach for insertion of the the RP Flex. and discusses a case highlighting weaning protocols and strategies for right-side support devices.

In his concluding remarks regarding use of the RP Flex he emphasizes, “Thinking of this as a salvage, or Lazarus kind of device, is the wrong attitude to have. I think this is a pre-emptive strike when you are worried about right ventricular dysfunction and to kind of get ahead of it and this can really pull you out of that fire before it even starts.”

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