Impella® Management in the CCU: Inotrope Weaning, Repositioning, Invasive Monitoring, Impella Heart Pumps and ECMO

Joseph Parrillo, MD, Brian Porvin, DO, and Steven Keller, MD, PhD, discuss managing patients with the Impella heart pump in the CCU. They focus on weaning off inotropes, repositioning Impella, invasive monitoring, and use of Impella and ECMO.

In chapter 1, these three intensivists discuss specific management recommendations for the use of pressors in patients with AMI cardiogenic shock, as well as Impella repositioning responsibilities within their institutions.

The physicians discuss the hemodynamic targets that indicate flow is reestablished and vasopressor support can be down titrated. They agree that the primary goal is to offload the left ventricle and decrease the pressure that the LV and Impella must work against to restore systemic perfusion. Dr. Porvin explains some additional measures for confirming both peripheral and cerebral perfusion.

With regard to Impella repositioning, all three physicians agree that intensivists are typically very skilled in determining Impella position with bedside echo and most are also comfortable repositioning the device. Dr. Parrillo describes a team approach to repositioning, noting that he sees cardiac surgery intensivists as the experts when it comes to repositioning the Impella device while the interventional cardiologists are the experts when it comes to initial Impella placement.

In chapter 2, all three physicians acknowledge a growing recognition of the importance of invasive hemodynamic monitoring in patients in cardiogenic shock who require Impella for hemodynamic support. Dr. Porvin mentions following the Detroit Cardiogenic Shock Initiative best practices. Dr. Parrillo recognizes that some cardiologists and intensivists remain reluctant to put in PA catheters, but he emphasizes the importance of the data gathered from invasive hemodynamic monitoring. “In certain patients, if you don’t know what the hemodynamics are, you’re not managing the patient optimally.”

In chapter 3, the physicians discuss the growing use of Impella as a strategy for both unloading and transition when it comes to ECMO. They describe the importance of LV unloading strategies, such as early insertion of an Impella device, to offload the left ventricle. Dr. Keller explains the risks of not placing Impella early and emphasizes the strong physiologic argument supporting unloading of the LV to decrease myocardial oxygen consumption, decrease myocardial work, and promote cardiac recovery. The physicians also discuss the shortcomings of using pulse pressure and other invasive hemodynamics to evaluate pulsatility and forward flow. They conclude their discussion by describing how each of their institutions decides when to choose Impella and when to choose ECMO and what the progression from one to the other may look like.