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Right ventricular failure has a high morbidity and mortality in patients suffering from advanced heart failure, pulmonary hypertension, acute myocardial infarction after cardiac surgery and in left ventricular assist device patients. The Impella RP® catheter is a mechanical circulatory device, positioned from a venous femoral percutaneous access and passing through the tricuspid and pulmonary valves, reaches the pulmonary artery. Impella RP (Abiomed Inc., MA, USA) acts as a direct right ventricle bypass and it provides a flow up to 4.4 liters per minute, unloading the right ventricle. The main contraindications are: thrombi in the vena cava, right atrium and ventricle and pulmonary artery; mechanical tricuspid or pulmonary prostheses. In this review, the principles of operations, clinical applications and results of Impella RP are summarized and evaluated. [ABSTRACT FROM AUTHOR]

Due to the scarcity of data, Impella RP is not approved for acute right ventricular failure caused by massive pulmonary embolism. We describe here the successful use of Impella RP in acute right ventricular failure caused by massive pulmonary embolism to highlight its promising outcome in such an indication. (Level of Difficulty: Advanced.)

Background: Right ventricular failure (RVF) is associated with increased mortality among patients receiving left ventricular mechanical circulatory support (LV-MCS) for cardiogenic shock and requires prompt recognition and management. Increased central venous pressure (CVP) is an indicator of potential RVF.Objectives: We studied whether elevated CVP during LV-MCS for acute myocardial infarction complicated by cardiogenic shock is associated with higher mortality.Methods: Between January 2014 and June 2019, we analyzed hemodynamic parameters during Impella LV-MCS from 28 centers in the United States participating in the global, prospective catheter-based ventricular assist device (cVAD) study. A total of 132 patients with a documented CVP measurement while on Impella left-sided support for cardiogenic shock were identified.Results: CVP was significantly higher among patients who died in the hospital (14.0 vs. 11.7 mmHg, p = 0.014), and a CVP >12 identified patients at significantly higher risk for in-hospital mortality (65 vs. 45%, p = 0.02). CVP remained significantly associated with in-hospital mortality even after adjustment in a multivariable model (adjusted OR 1.10 [95% CI 1.02–1.19] per 1 mmHg increase). LV-MCS suction events were non-significantly more frequent among patients with high vs. low CVP (62.11 vs. 7.14 events, p = 0.067).Conclusion: CVP is a single, readily accessible hemodynamic parameter which predicts a higher rate of short-term mortality and may identify subclinical RVF in patients receiving LV-MCS for cardiogenic shock.

Over the last years, different case reports/studies have demonstrated that in patients with acute pulmonary embolism (PE) and refractory shock mechanical circulatory support (MCS) with Impella RP® (Abiomed, Inc, Danvers, Mass) increases the chances of survival, significantly unloading the right ventricle and improving both the cardiac output and the mean pulmonary artery pressure. We reviewed the medical literature about the use of Impella RP in patients with acute PE and refractory shock using PubMed (MEDLINE), Scopus, Cochrane library, and Google Scholar databases. The final research was conducted in July 2019. The results evidenced that available data are currently scant to definitively assess the real role Impella RP® in patient with acute PE and refractory shock. However, preliminary data seems to be very promising. Further larger studies are needed to confirm the safety and efficacy of MCS in these patients. A multidisciplinary assessment, using the PERT team, must be performed case by case to determine the need of MCS. [ABSTRACT FROM AUTHOR]

Temporary mechanical circulatory support devices for the treatment of acute right ventricular failure represent crucial tools for clinical practice. Right ventricular failure presents specific treatment issues, and dedicated percutaneous devices are less in number compared to the left ventricle. Current data and insights on mechanical circulatory support for the right ventricle come mostly from the context of cardiac surgery, predominantly the setting of acute right ventricular failure after left ventricular assist device implantation. The Impella RP (Abiomed, Danvers, MA) is a minimally invasive temporary device that has gained application for the percutaneous treatment of right ventricular failure with positive clinical results. Even though treatment indications are clear, technical and management issues still are relevant because of the limited scientific data available. Appropriate positioning and repositioning, interaction with right ventricular valvular apparatus, anticoagulation management, weaning, and patient mobilization are examples of the open challenges. In line with the positive initial experience with this device, future research efforts should be focused on the improvement of device limitations and on providing additional data that might drive optimal clinical management. [ABSTRACT FROM AUTHOR]

Background: Right ventricular (RV) failure due to pulmonary embolism (PE) increases morbidity and mortality and contributes to prolonged hospital length of stay and higher costs of care. RV mechanical circulatory support (MCS) including Impella RP devices have been increasingly used in hemodynamically compromised PE patients who are refractory to intravascular volume expansion and inotropic therapy. However, effectiveness and safety of Impella RP, in hemodynamically unstable PE patients is unknown.Methods: We included consecutive patients who presented to Detroit Medical Center between November 3, 2015 and October 2, 2017 with acute PE and had evidence of hemodynamic compromise indicating Impella RP.Results: Total of five cases were identified. All patients met the shock definition due to massive or submassive PE and therefore received Impella RP on admission. Cardiac index was improved from mean of 1.69/min/m2, (0.88-2.15 L/min/m2 ), to 2.5 L/min/m2 (range 1.88-3.4), after 24 h of treatment. Similarly, mean heart rate reduced to 92 beats per minute (79-105), and mean systolic blood pressure increased to 140 mmHg (115-179). No significant changes were found in renal function, hemoglobin and platelets level during device use. One patient experienced hemoglobin drop from 13.7 to 7.3 g/dL but did not require blood transfusion. All patients survived to discharge.Conclusion: In patients with PE and RV shock, Impella RP device resulted in immediate hemodynamic benefit with reversal of shock and favorable survival to discharge. [ABSTRACT FROM AUTHOR]