Impella Education, Insertion, Right Heart Failure

Robert Salazar, MD: Early Experience With Impella RP Flex™ with SmartAssist®


Robert Salazar, MD, discusses his early experience with Impella RP Flex™ with Bobbi Bogaev Chapman, MD. Dr. Salazar is an interventional cardiologist and director of cardiovascular research at Kingwood Hospital in Houston, Texas. 

Dr. Salazar explains that because the RP Flex does not have a defined shape like the Impella RP® with SmartAssist®, the RP Flex is much more trackable and maneuverable and “much simpler to deliver.” While his partners have inserted the RP Flex from the groin, their first expereince was with a right internal jugular (IJ) approach. “The RP Flex is very stable,” he states, emphasizing that they primarily verify positioning with chest X-rays because they cannot fully visualize the inlet and outlet positioning using echocardiography.

Dr. Salazar reports, “timing is paramount” with insertion of the RP Flex. As soon as he suspects right ventricular failure or cardiogenic shock, he gets an immediate right heart catheterization. He also discusses symptoms and biomarkers that may be indicative of right ventricular failure. 

With regard to  weaning,  Dr. Salazar explains, “Both the RP Flex and the RP with SmartAssist provide some very useful data right on the console. That includes the PAPi, which is one of the most useful ones. The derived value of that PAPi is quite accurate and very consistent with what we found with the Swans that we’ve left in.” He also describes using echocardiography to confirm that the right ventricle is contracting and not severely dilated before weaning patients. In addition, he ensures lactate levels have fallen consistently and urine output is stable or increasing. His team may start looking at weaning after 12 hours of support and are often able to wean or remove the device at about the 24-hour mark. “We’ve discovered that the right ventricle is actually quite resilient, and comes back very quickly once its supported."

Dr. Salazar also briefly discusses ambulating patients supported with the RP Flex and his approach to anticoagulation. When asked about tips and tricks, he emphasizes that purse-string sutures at the neck are especially helpful and very straightforward. He reports no concerns with hematomas or bleeding at the insertion site.

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