Impella® Skills Video: Insertion Steps for the Impella CP® with SmartAssist®

This Impella® Skills video demonstrates the insertion steps for the Impella CP® with SmartAssist® heart pump. 

1. Obtain femoral access and insert a 6-8Fr sheath into the vessel.
2. Insert the 0.035” stiff guidewire provided in the Introducer Kit.
3. Remove the sheath and sequentially dilate the tissue tract.
4. Insert the 14Fr peel-away sheath.
5. Administer an anticoagulant to achieve an ACT of at least 250 seconds.
6. Once the desired ACT is reached, remove the dilator from the sheath.
7. Insert a diagnostic pigtail catheter with a standard 0.035” J-tip guidewire and advance it into the left ventricle.
8. Remove the 0.035” standard J-tip guidewire, leaving the diagnostic catheter in place.
9. Form a curve on the end of the 0.018” placement guidewire and insert it through the diagnostic catheter, advancing the placement guidewire into the left ventricle to the apex.
10. Remove the diagnostic catheter.
11. Slide the repositioning sheath down to the red pump plug to allow for additional working length of catheter during insertion.
12. Insert the end of the placement guidewire into the red EasyGuide lumen at the tip of the pigtail and advance the guidewire through the red lumen until it exits the lumen near the label. Gently pull the label along the length of the catheter to remove the red EasyGuide lumen.
13. Advance the Impella catheter through the hemostatic valve into the femoral artery and follow the catheter under fluoroscopy as it is advanced across the aortic valve using a fixed wire technique.
14. Under fluoroscopy confirm that the inlet area of the catheter is positioned approximately 3.5 cm below the aortic valve annulus and in the mid-ventricular space. An aortic waveform should be displayed on the Automated Impella Controller™.
15. Remove the placement guidewire and press the START IMPELLA soft key on the console to initiate support. On the next screen press YES to confirm that the guidewire had been removed and start the pump. Flow will reach maximum value after a 30-second ramp-up.
16. Using fluoroscopy and the placement screen, confirm correct and stable placement and remove any excess slack.
17. Maintain ACT at 160 to 180 seconds after insertion and until explant.
18. If the patient is transferred to the ICU with Impella in place, remove the 14Fr peel-away sheath and replace it with the repositioning sheath. 
     
    1. To remove the peel-away sheath:
       • Flush the sidearm of the peel-away introducer and ensure the sheath is completely out of the body prior to peeling it away.
       • If using the 14Fr x 25cm peel-away sheath, it may be necessary to push the sheath over the repositioning sheath to fully remove from the body prior to peeling it away.
       • Once the peel-away sheath is fully removed from the body, snap the wings of the peel-away sheath and separate the sheath completely from the catheter. 
    2.  To use the repositioning sheath:
       • While pinning the Impella catheter shaft, advance the repositioning sheath fully into the arteriotomy. Do NOT insert the blue hub into the tissue tract.
       • Suture the blue suture pad to the skin using a forward suture.
       • Maintain the angle of insertion and, if needed, place a folded 4x4 gauze pad under the hub of the sheath.
          
19. Under fluoroscopic guidance, pull the catheter back until it rests on the inner curvature of the aorta to remove any slack in the catheter.
20. Connect the sterile sleeve to the repositioning unit and secure by tightening the Tuohy-Borst valve until finger tight.