Impella® Skills Video: Escalation from Impella CP® with SmartAssist® to Impella 5.5® with SmartAssist®

This Impella skills video demonstrates the steps of escalation from the Impella CP with SmartAssist to the Impella 5.5 with SmartAssist heart pump. The video is a simplified version of the technique, highlighting the primary steps of the procedure.

1. To initiate insertion of the Impella 5.5 with SmartAssist, expose the axillary artery and apply vessel loops proximal and distal to the point of incision.
2. Make an incision between the vessel loops.
3. Attach a 10 mm x 20 cm woven Dacron vascular graft to the artery using at least a 60-degree bevel to facilitate passage of the Impella into the graft.
4. Clamp the graft above the anastomosis.
5. Insert the provided 23Fr peel-away introducer into the graft and secure with one of the provided graft locks to maintain hemostasis while making the wire exchange in the ventricle.
6. Ensure ACT is at least 250 seconds.
7. Release the clamp and insert a 4Fr to 5Fr diagnostic catheter into the sheath with a 0.035” guidewire and cross the aortic valve.
8. Remove the 0.035” guidewire and replace it with the provided 0.018” placement guidewire, advancing it into the apex of the left ventricle.
9. Remove the diagnostic catheter leaving the 0.018” guidewire in place.
10. Place a soft-jaw vascular clamp on the graft above the anastomosis to maintain hemostasis during insertion.
11. Load the provided 8Fr silicone-coated dilator onto the 0.018” wire and advance it through the hemostatic valve several times, allowing the silicone to lubricate the valve to aid insertion of the Impella catheter.
12. Remove the dilator from the 0.018” wire.
13. Prior to inserting the Impella 5.5 with SmartAssist over the wire, lay the catheter out straight and remove any excess torque in the catheter and white connector cable.
14. Hold the catheter upright and visualize purge fluid at the base of the impeller.
15. Load the Impella 5.5 with SmartAssist over the wire, ensuring that the wire exits the inner radius of the Impella catheter.
16. Under fluoroscopic guidance, advance the Impella 5.5 with SmartAssist into the axillary artery just proximal to the aortic arch.
17. Have an assistant loosen the Tuohy Borst valve on the Impella CP with SmartAssist catheter.
18. Reduce the performance level (P-level) to P-1. 
19. Under fluoroscopic guidance, pull the Impella CP with SmartAssist out of the ventricle and into the descending aorta, paying careful attention to the pigtail as it clears the 0.018” guidewire in the ascending aorta.
20. Advance the Impella 5.5 with SmartAssist across the aortic valve under fluoroscopic guidance.
21. Use TEE to confirm proper positioning of the Impella 5.5 with SmartAssist, ensuring the inflow is in the mid-ventricular cavity or along the septal wall.
22. Echo measurement should reveal that the mid-inlet of the Impella 5.5. with SmartAssist is approximately 5 cm below the aortic valve annulus.
23. Ensure that the inlet cage is directed toward the apex of the left ventricle and away from the mitral valve apparatus.
24. Remove the 0.018” guidewire.
25. Once the guidewire has been removed, initiate Impella 5.5 with SmartAssist support at P-2 and slowly increase the P-level to the desired level of Impella flow and hemodynamic support.