PACE Exam

Scenario: Hematuria (7)

- When did the urine change color? - Test PfHgb, UA. - Assess volume (CVP). - Check alarm history. - Assess position and RV function with echo. - Decrease P-level if tolerated. - If hemolysis persists, reposition pump.

"Low Purge Pressure"

- check all connections for tightness. - change purge cassette. - increase dextrose concentration. - **watch motor current.

High/low purge pressure actions

- kinks/leaks - increase/decrease viscosity of dextrose - replace cassette -*Monitor MC

normal CPO

1-1.5 watts

Normal Purge Flow for 5.5 with SmartAssist

1-30ml/hr

5.0 graft insertion with silicone plugs

1. Bevel 10x20 graft at 45-60 angle and anastomose to artery (axillary or fem) using vessel loops for bleeding until graft can be clamped. 2. Use a 6-10F sheath to control bleeding, unclamp graft and access LV with catheter and 0.035. Exchange for 0.018, remove catheter. 3. Clamp graft at anastomosis and remove sheath, leaving 0.018 in place. 4. Attach pre-split plug proximal to motor and backload pump. 5. Secure silicone plug in graft with ties/suture, remove clamp, advance pump into LV, remove wire, begin support. 6. Clamp graft over Impella. Remove plug and trim graft. Using vessel loops for bleeding, unclamp graft and advance and secure repo sheath into graft.

What are the most common measures of LV preload?

1. EDP 2. EDV 3. PCWP

Describe the differential pressure sensor of the 5.0, LD, and RP (4)

1. flexible membrane integrated into the cannula 2. generates PS 3. used to monitor position and calculate flow 4. PS = outlet pressure - inlet pressure

What affects ventricular contractility? (3)

1. pH 2. myocardial mass 3. ischemia/infarct

Pressure volume area is a measure of (3)

1. stroke work 2. potential energy 3. total mechanical energy that correlates with myocardial O2 consumption

2.5 MC threshold

1010

graft size for 5.0 placement

10mm x 20cm

CP MC Threshold

1130

RP/5.0/LD MC Threshold

1190

Catheter Fr size for RP

11F

normal PVR

120-250 dynes/sec/cm2

CP with SmartAssist MC Threshold

1200

Cannula size 2.5

12F

Motor size of 2.5

12F

Sheath included with 2.5

13F x 13cm

Cannula size of CP

14F

Motor size of CP

14F

Sheath included with CP

14F x 13cm 14F x 25 cm

Repositioning sheath size for RP

15F OD

Motor size of 5.5

19F

Normal Purge Flow

2-30ml/hr

Normal CI

2.5 - 4L/min/m2

Cannula size of 5.0 and LD

21F

Cannula size of 5.5

21F

Motor size of 5.0 and LD

21F

Cannula size of RP

22F

Motor size of RP

22F

Sheath included with RP

23F x 30cm

Sheath included with 5.0 and LD

23F x 6cm

Contents of the Axillary Insertion Kit

23F x 6cm sheet 2 grafts locks 8F silicone coated dilator

Using the RP, if flows are <1.5L/min, what should the ACT be?

250sec

Normal Purge Pressure

300-1100mmHg

Minimum vessel size for 2.5

4.3mm

Min vessel size for CP

4.7mm

After zeroing the RP, what should the PS read?

4/4 +/- 10mmHg

How long should manual pressure be held for 13/14F sheath?

40 mins

How long are purge cassettes designed to perform?

5 days

Max flows of 5.0 and LD

5L/min

Why does the 5.5 have to be placed axillary?

70cm catheter length

Repositioning sheath size for 2.5

9-13F x 10cm

Repositioning sheath size for CP

9-13Fr x 12cm

How long should it take to change the purge system/bag?

90 seconds.

What is the maximum working length of the catheter?

93-99cm

Catheter Fr size for 2.5, CP, 5.0, 5.5, and LD (5 catheters)

9F

Repositioning sheath size for 5.0

9F, non-tapered

2.5 and CP indication for HRPCI

< 6 hours hemodynamically stable severe CAD surgical turndown

If the placement signal lumen is blocked, what is the pulse pressure?

<10mmHg

RP indications

<14 days pt with BSA >1.5m2 with acute RH failure or decompensation after LVAD implant MI transplant open heart

2.5 and CP, 5.0 and LD indication for CGS

<4/14 days immediately (<48hrs) following 1. AMI 2. open heart surgery 3. CM (including peripartum) 4. myocarditis 5. LV failure

goal CPO on Impella

>0.7

CI goal on Impella

>2.2L/min/m2

Max flows of RP

>4L/min

Min vessel size for 5.0

>7mm

Impella Stopped.

"Controller failure"? yes - replace console. No... Restart at previous P-level. Restart at P-2. Wait 1 minute, reattempt at P-2. Replace pump. *If you can't get the pump restarted, pull the catheter back across AoV. Treat medically PRN.

"Placement Signal Lumen Blocked"

*Only seen in 2.5 and CP w/o SA. Threshold for this alarm: PP <10mmHg. Likely clot. Make sure pressure bag is properly inflated to 300mmHg. Take 20cc syringe and aspirate the red connection port. -If it clears, flush and reattach pressure bag. -If you can't aspirate, cap off pressure port. Disable placement signal (under Menu). **Will lose suction alarms and PS. Monitor MC.

Scenario: It's the doc's first case and they have never done anything larger than an 8Fr. (3)

- Discuss manual pressure for first case. - Recommend having doc with large bore access experience in the case. - Make sure peripheral angio shows vessels suitable for closure; work with Abbott prior to first case.

Scenario: blue, mottled foot (7)

- Recognize it's blue and cold. - Recognize the difference between pedal, PT, and pop pulses. - If pt is small enough, can repo sheath be pulled back slightly? - If pressures allow, can we vasodilator to dilate vessels? - Stable enough to wean? - Consider alternative access. - Consider peripheral fem-fem bypass.

Scenario: Clot entrainment (5)

Advise doc to remove device. ACT should be performed and it should be >250. Place new pump. Fill out SPR. Echo for possible LV clot.

After backloading the 2.5/CP over the 0.018 wire, what do you do next?

Aspirate and flush sheath. Then insert Impella

Pink urine and doc asks if it could be the Impella.

It's possible, however studies show when the pump is correctly positioned and patient has appropriate volume, the incidence of hemolysis are clinically insignificant. Suggest sending plasma-free Hgb and UA. Order an echo to evaluate position

Contraindications for L sided pumps

LV thrombus LV rupture ASD/VSD mechanical AoV severe AS Mod-severe AI Severe PVD significant RH failure tamponade combined cardio-resp failure

5 soft buttons on the AIC

Mute, Flow Control, Display, Purge menu, Menu

Does the RP have a "Home Screen"?

No.

If the 5.0 is too far into the LV, will the PS look ventricular?

No.

How to wean patient in ICU

Off all pressers and tropes? Yes - great. Decrease P-levels x2, Q2-4hr. Assuming pt is stable, MAP >60mmHg or LVEDP with SA, continue decreasing at this rate. Be at P-2 when ready to pull. P-1 and pull back across valve. P-0 and pull pump and sheath as one unit. Hold pressure. Pull white cable, turn off AIC.

Using the RP, what should the P-level be kept above?

P-6

PAPI =

PAs-PAd / CVP. Pulmonary Artery Pulsatility Index

What is considered filling pressure of the left heart?

PCWP

Causes and resolution of "Purge System Blocked" alarm

PF <1ml/hr Check for kinks, decrease dextrose viscosity, replace cassette Monitor MC.

Scenario: Recommended echo images for ICU (4)

PLAX to measure 3.5cm from annulus. Identify inlet cage, AoV, cannula, pap muscle, MV pigtail to apex. Add color to evaluate mosaic flow above AoV. Recommend action if it needs repositioned.

Cause of "Impella Position Unknown"

PP <20mmHg *Assess MAP

"Impella Position Wrong"

PS: AO. MC: flat. Home Screen will show "Impella Position Wrong" with a question mark. Drop to P-2. Get an echo to determine where the catheter is (3 options): entire catheter in AO. entire catheter except pig in AO. inlet and outlet in LV with OPP in AO. 5.0/LD - too far in/too far out.

Talk through weaning the RP

Perform trial wean and view echo to confirm RV contractility. Decrease to P-2 for no longer than 15-20 mins. Record flows, P-level, CVP, echo parameters, and demos. Once contractility is again confirmed, resume previous P-level and slowly wean. Decrease x2 P-levels Q2-3 hours and monitor memos. *Always maintain flows >1.5L/min until removed.

How is the RP properly positioned in the heart?

Pigtail in LPA silver ball of outlet to PV should be 2-4cm 1st turn at PV 2nd turn at TV 3rd turn at IVC/RA junction Inlet level of diaphragm or apex

Options under Display

Placement Screen Home Screen (2.5/CP/5.0/LD) Purge screen Infusion history Y-axis Time scale Center functions

Impella is ___ dependent, ___ sensitive.

Preload dependent. Afterload sensitive.

"Air in Line"

Purge Menu Deair purge.

Critical alarms: color, frequency?

Red 10 beeps every 6.7 seconds

IABP with Impella. Actions and considerations?

Reduce IABP to 1:3 and 50% augmentation. Remove ASAP. False suction alarms, position alarms, increased chance of hemolysis, lower flows

What is the measuring device called that is included with the LD?

Sterile incision template.

RP and suction: If position and preload are acceptable, and cannot resolve suction alarm at P-2 or P-3, what should you do?

Stop RP to break suction. Immediately restart at P-2 and gradually increase to desired P-level.

AIC states "Impella Position Unknown". Family member asks you what it means.

Talk to the nurse. RN explains that it's normal because the pump has taken over for the heart. Continue to watch and evaluate MAP. Turn off alarm.

Once the RP is in the RV, what should you do?

Torque clockwise to rotate pig towards PV. Advance 2-4cm into PA. Remove wire slowly under fluoro. Start and P-2 and slowly increase.

Transferring AIC to AIC

Turn on Console B. Disconnect white cable from console A, plug it into console B. Press the selector knob to accept the previous settings. Disconnect the yellow leur locks and reconnect it. Transfer purge cassette and purse solution to console B. Purge Menu to change purge fluid bag and estimate remaining volume.

Suction alarms

Volume = CVP? Placement = echo? RV failure = PAPi, echo, liver enzymes? If pt can tolerate lower P-level, no need to escalate to RP.

When do you see MC spikes on the RP? And why?

When the device is set to P-6 or lower. Spike are due to pulsatility added to the pump at lower P-levels. You can disable the spikes by going to Menu-Settings & Service-Disable MC Spikes.

Advisory alarms: color, frequency?

White 1 beep every 5 mins

Serious alarms: color, frequency?

Yellow 3 beeps every 15 seconds

Repositioning sheath size for 5.5

blue suture pad only

CPO is a measurement of

cardiac function accounting for pressure and flow generated by the heart

5.0 Kit Contents

catheter purge cassette connector cable silicone plugs 0.018 x 260 wire axillary kit (23F x 6cm sheet, 2 grafts locks, 8F silicone coated dilator)

Purge menu options:

change purge fluid bag change cassette and bag de-air transfer to standard config (only on 2.5)

Placement measurement of 5.0, LD, and RP

differential pressure sensor

Anatomically, what can interfere with inflow of RP?

eustachian valve

Placement measurement of 2.5 and old CP

fluid filled open pressure port

If alarm has been resolved, how is it displayed?

in gray for 20 minutes, or until you press Mute

Secondary endpoint in Protect II, the Impella provided better hemodynamic support compared to IABP by

measuring the maximal decrease in CPO from baseline

CPO of <0.6 is an indicator of

mortality

Placement measurement of new CP and 5.5 (Smart Assist)

optical sensor

Recognize low pulsatility before re-zeroing 5.0 and LD. If A-line is nonpulsatile:

patient may not tolerate dropping to P-2 for the zero.

What type of suture do you need to use with the silicone plugs?

penetrating

What type of alarm does the RP not have?

position alarms

SV is dependent on (3)

preload, after load, and contractility

Best practices to prevent device movement

remove slack in CCL tighten Tuohy note cm marking baseline echo in ICU prevent unnecessary pt movement

Why does CPO have the strongest hemodynamic correlation to mortality?

sensitive to end organ perfusion because it accounts for pressure and flow

LVEDP is reflective of ___ and ___ of the blood in the LV during ___.

volume, pressure, diastole.

Fellow believes the patient has HIT.

HIT is 50% drop in platelets after Heparin administration. Can we run an ELISA or SRA to confirm? If confirmed, contact medical officer to get appropriate alternative of Angiomax or Argatroban.

Sudden drop in flows...

-probably a clot. What was the ACT? Did you flush the sheath? Reduce to P-1, pull back across AoV. Replace pump.

LD Insertion

1. Sterile incision template at AoV annulus, so placement is >7cm from valve. 2. Use side biter clamp, make incision <6mm. 3. Attach 10x15 graft the Asc AO and clamp at the anastomosis. 4. Push both silicone plugs flush to the motor, and insert Impella into graft. 5. Secure rear plug with ties/suture and remove clamp. 6. Advance Impella under TEE until across AoV; front plug will advance until it is flush to AO. 7. When across the valve, start at P-2 and increase. 8. Ensure front plug is flush against AO, and secure with penetrating suture. 9. Remove rear plug. Remove blood. Readvance rear plug against front plug and secure with penetrating suture. 10. Trim graft.

According to Recover Right, how can RH failure be diagnosed? (3)

CI <2.2L/min/m2 AND CVP >15mmHg CVP/PCWP >0.63 confirmed by echo

CPO =

CO x MAP / 451

What is the strongest hemodynamic correlation to in-hospital mortality according to SHOCK trial?

CPO

What is considered filling pressure of the right heart?

CVP

Needed but not included for 2.5 insertion

D5W diagnostic catheter J-wire dilators

After removing the peel away sheath and advancing the repo sheath, what's next?

Forward suturing Attach anti contamination sleeve Tighten Touhy Angle match confirm placement.

If the AIC detects a blocked purge system, what will it do?

Increase to 1500mmHg for up to 5 mins in attempt to clear the blockage.