Impella RP Flex^TM Management: Medical Science Office Discussion

Bobbi Chapman, MD, Navin Kapur, MD, and Andy Shaw, MD, discuss best practices for managing patients supported with Impella RP Flex^TM with SmartAssist^TM once the patient is transferred to the ICU.

William Lowe, Manager Advance Training at Johnson & Johnson MedTech, asks the physicians about mitigating thrombus ingestion and Dr. Chapman emphasizes the importance of turning the Impella RP Flex with SmartAssist down to P2 when manipulating the PA catheter or pulling a dialysis line or other central line in the patient. She also emphasizes the importance of anticoagulating the patient at the time of the procedure and maintaining anticoagulation after the procedure. “ You don’t have the luxury of just doing bicarb in the purge like you would with the [Impella] 5.5. It’s important to get them anticoagulated therapeutically as soon as possible and to maintain a therapeutic systemic anticoagulation with an ACT between 160 to 180, and I would err on the higher side of that to mitigate any development of a thrombus on another line that could potentially embolize and be ingested into the device.”

The physicians discuss protocols for monitoring anticoagulation using ACT, PTT, and anti-Xa. “You can’t legislate one size fit all, because it doesn’t,” Dr. Shaw explains emphasizing that it is important for the staff to use the anticoagulation strategies with which they are familiar. “It’s important to understand there’s variability from hospital to hospital,” Dr. Chapman adds, “and that each hospital should follow the protocols that have been set and established at their hospital.”

The physicians also discuss special considerations for patients with biventricular failure who are supported with both left- and right-sided mechanical circulatory support devices, a practice referred to as “BiPella” support when two Impella devices are used. Dr. Kapur highlights three particular BiPella support considerations: (1) simultaneous, not staged, BiPella support, (2) “permissive hypervolemia,” with CVP targets in the 10+ range, to optimize conditions until you have lactate normalization,” and (3) weaning considerations, which typically entail weaning the patient off right-side support first with persistent left-sided support in biventricular failure cases.

BiPella support often entails two percutaneous devices, Impella CP^TM with SmartAssist^TM for left-sided support and Impella RP Flex^TM with SmartAssist^TM for right-sided support. Sometimes, however, patients require escalation to Impella 5.5^TM with SmartAssist^TM on the left. Dr. Shaw’s motto is “Escalate early and escalate often,” as many shock patients will require more than the 3.5 liters of support supplied by the Impella CP.