Pitfalls due to improper positioning of Impella®CP device for left ventricular support: a case series

Background: The Impella® device is a type of antegrade left ventricular assist device that includes a pump catheter designed to reside in the mid-left ventricular cavity. It has received approval for temporary use in providing left ventricular support, with the aim of augmenting cardiac output and reducing myocardial oxygen demand. We document four cases in which we encountered challenges in circulatory management during Impella device insertion. These challenges arose from issues such as incorrect positioning leading to restricted maximum flow rate or the development of new-onset aortic insufficiency (AI) associated with the placement of the device. Cases presentation: Two of our four patients showed improper positioning; either the inlet part was too much in the ventricle or too close to the heart wall. Due to the placement of the Impella, all four patients experienced the development of new-onset aortic insufficiency with a relatively low total assisted flow rate. In one of the cases, sufficient total flow was achieved when the Impella device was utilized alongside veno-arterial extracorporeal membrane oxygenation (ECMO). Conclusion: Circulatory management with Impella device insertion can be challenging due to certain pitfalls, such as the incorrect positioning of Impella and the development of AI following Impella placement with a restricted flow rate. During the acute phase when patients experience deteriorating cardiogenic shock, the use of ECMO for management is considered to be an effective approach. Abbreviations: ECMO: Extra-corporeal membranous oxygenation; PCPS: Percutaneous cardiopulmonary support; LVAD: Left ventricular assist device; LVEF: Left ventricular ejection fraction; CCO: Continuous cardiac output; AI: Aortic insufficiency. Keywords:  Aortic Insufficiency; ECMO; Cardiogenic Shock; Impella; Ventricular Assist Device Citation: Abdalwahab A, Ismail AA, Hammad YM. Pitfalls due to improper positioning of Impella®CP device for left ventricular support: a case series. Anaesth. pain intensive care 2024;28(5):119-123. DOI: 10.35975/apic.v29i1.2656 Received: November 24, 2024; Reviewed: December 30, 2024; Accepted: December 30, 2024