Impella RP Flex^TM Weaning and Explant: Medical Science Office Discussion

Navin Kapur, MD, Bobbi Chapman, MD, and Andy Shaw, MD discuss clinical conditions for weaning and explanting the Impella RP Flex^TM with SmartAssist^TM.

“I look at hemodynamic and metabolic conditions on the dashboard,” Dr. Kapur states. Hemodynamically, can patients maintain cardiac output and mean arterial pressure when support is turned down? Metabolically, has end-organ dysfunction resolved and does the patient have good overally systemic perfusion? Dr. Kapur also discusses the importance of the pulmonary artery pulsatility index (PAPi) for weaning.

Dr. Shaw adds the importance of checking for suction on the left as you turn down flow, and looking at the dimensions of the left and right ventricles and septal positioning with echocardiography.“I think the question that needs to be answered is ‘Can the right side fill the left on its own?” he states.

For patients on BiPella support—hemodynamic support from both a left- and a right-sided Impella device—Dr. Kapur explains that usually they wean the right-sided device first to assess whether the left-sided device has enough preload. “Once you start to see that you’re able to wean the right-sided device, usually you can then start testing the waters with the left-sided device.” Sometimes, however, patients need to be escalated on the left side, which, Dr. Kapur explains, may actually help patients come off right-sided support. “Doing it sequentially is really important, instead of simultaneously,” he emphasizes.

With regard to explanting the device, Dr. Kapur highlights the relative ease of removing the Impella RP Flex^TMand achieving hemostasis, given that the device is in the venous system. “Manual compression with a purse-string is pretty effective,” he states, as long as you monitor anticoagulation. Dr. Chapman explains that if the center does not have a lot of experience explanting the Impella RP Flex, they can take the patient to the cath lab and explant under fluoroscopy; however, most experienced centers are doing bedside explants.

Dr. Kapur adds that another important consideration is device repositioning. He emphasizes that, especially in patients with marginally functioning right ventricles, the tissue is quite friable and Impella RP Flex repositioning should be done with imaging guidance. “Generally for repositioning we would go back to the cath lab and use a combination of echo and fluoroscopy,” he states.