Role of Impella in Cardiac Arrest Management

Device Overview and Classification

The Impella is classified as a nondurable, percutaneous, continuous-flow, axial pump with an external controller that provides temporary mechanical circulatory support, with different models available, including Impella 2.5, which provides up to 2.5 L/min of flow, and Impella RP, designed specifically for right ventricular support, according to Praxis Medical Insights 1

The American Heart Association recommends that it may be reasonable to use extracorporeal cardiopulmonary resuscitation (ECPR) as a rescue treatment when initial therapy is failing for cardiac arrest that occurs during percutaneous coronary intervention (PCI) 2
The American Heart Association suggests that mechanical CPR devices may be considered to provide chest compressions to patients in cardiac arrest during PCI 2
The American Heart Association advises that institutional guidelines should include appropriate candidate selection for mechanical support devices to ensure they are used as a bridge to recovery, surgery, transplant, or other device 2
For pregnant women with cardiac arrest due to suspected pulmonary embolism, the Society of Critical Care Medicine recommends that extracorporeal membrane oxygenation (ECMO) may be considered as an acceptable salvage therapy 3

The American College of Cardiology suggests that Impella may be considered for cardiogenic shock following cardiac arrest, particularly after acute myocardial infarction 1
The American Heart Association recommends that Impella may be used as a bridge to recovery when left ventricular function is expected to improve 2

Vascular complications are more common with Impella compared to IABP (9.8% vs 3.8%) 1
The device has maximum flow limitations that may be inadequate for patients with large body mass or severe cardiogenic shock 1
Contraindicated in patients with left ventricular thrombus, severe aortic stenosis, severe peripheral artery disease, or aortic disease 1

Anticoagulation is required to prevent pump thrombosis, with an initial unfractionated heparin bolus of 100 U/kg (up to 5000 U maximum) at the time of implantation 1
Echocardiographic assessment is crucial for evaluating improvements in left ventricular function during weaning 1
For patients failing initial weaning attempts, consider longer support duration or transition to more durable mechanical circulatory support devices 1

Unlike IABP, Impella devices offer greater left ventricular support 1
Compared to TandemHeart, Impella has a simpler design and implantation procedure 1
VA-ECMO provides biventricular support but may require additional left ventricular venting, potentially using an Impella, to prevent left ventricular distension 1

The American Heart Association recommends initiating standard ACLS protocols, including high-quality CPR, defibrillation for shockable rhythms, and administration of appropriate medications per ACLS algorithms, for patients with an Impella device who experience cardiac arrest 4, 5
Consider using mechanical CPR devices to provide consistent chest compressions, which may be particularly beneficial in a catheterization lab setting, allowing for continued fluoroscopy without radiation exposure to personnel 4, 6

The American College of Cardiology suggests considering escalation to ECPR as a rescue treatment if initial resuscitation efforts fail, particularly if the arrest occurred during PCI 4, 5
For patients with suspected calcium channel blocker toxicity contributing to cardiac arrest with an Impella in place, administer IV calcium and consider lipid-emulsion therapy, as recommended by the Critical Care Medicine society 7

Institutional guidelines should include appropriate candidate selection for mechanical support devices, such as Impella, to ensure they are used as a bridge to recovery, surgery, transplant, or other device, according to the American Heart Association 4

The combination of ECPR and IABP has been associated with increased survival compared to IABP alone for patients with cardiogenic shock, including those who have cardiac arrest during PCI, as reported by the American Heart Association 4