CCT: Impella VAD

[VFlutter]

Just curious, Has anyone seen Impella VADs in the CCT enviroment? I would assume they would not be common since many of the places that are using them would be tertiary care centers and not likely to be transferring patients out.

For those not familiar the Impella is a newer percutanous VAD similar to a IABP. Impellas offload the LV while IABPs augment pressure. They can even be used together, which is rare. The main disadvantage is that the impella does not improve coronary perfusion as the IABP does.

http://www.abiomed.com/products/impella-cp/

 

[CANMAN]

The service I work for is doing some transfers of patients that have them in place, and we transport to our main tertiary care center which is messing with them now. They are being placed in the community hospital's cath labs, and some of the problems we are seeing with them are placement related. Clinically I don't think we have seen many patient's that are actually getting the promised cardiac output numbers with the Impella in place. While it moves more then an IABP, it's not the numbers advertised. I would be curious to see if this device hangs around, or falls by the wayside with the availability of ECMO in the transport environment.

 

[Handsome Robb]

I've had one cath lab to cath lab transfer where we showed up and the cath nurse kept care and I just assisted with an Impella. That's all though. We have a new cardiologist in town that is a big supporter of the device. He's a great doc too. Loves paramedics.

The things I've read as far as output though definitely seemed too good to be true. I don't have the experience to comment either way though.

 

[VFlutter]

Got a flight request the other day for a patient on biventricular Impella support. Impella RVAD and Impella CP LVAD. Unfortuenly, we didn't think we could fit two consoles plus the multiple CTs, Vent, pacer, 6 drips, etc in the 407.

 

[VentMonkey]

Got a flight request the other day for a patient on biventricular Impella support. Impella RVAD and Impella CP LVAD. Unfortuenly, we didn't think we could fit two consoles plus the multiple CTs, Vent, pacer, 6 drips, etc in the 407.

Hmmm, interesting, we were cancelled on a similar request a few nights ago. All I was told over the phone was it was a BiVAD, in hindsight I wonder if it was an Impella.

We found out later our vendor took the liberty of assuming we wouldn't be able to fit it in our 407, and cancelled us for their newly acquired service to the north with a 430.

Admittedly, I don't have any experience with impella, but I've wondered the same given their commonality with IABP's, but with seemingly more portability.

 

[E tank]

Got a flight request the other day for a patient on biventricular Impella support. Impella RVAD and Impella CP LVAD. Unfortuenly, we didn't think we could fit two consoles plus the multiple CTs, Vent, pacer, 6 drips, etc in the 407.

You'd think it'd be a no brainer for Abiomed to have a double console for ease of care, but they wouldn't be able to sell you another unit to buy then, would they? Only a matter of time till they or a competitor do that for the convenience of the folks that actually use the device...

 

[VFlutter]

A single Imeplla will fit in the 407, we have done a lot of training with the Abiomed reps. I think you could swing two if there wasn't a ton of other extra equipment which these patients almost always have.

Impella RVADs are not very common yet so we haven't seen any BiVADs until now. We didn't really focus on them during training since the rep told us that the only places that are approved to implant RVADs are destination centers who would not be transporting patients out. Seems like the rare case being those trying to get to transplant hospitals.

I bet eventually they will move towards one console just like EKOS catheters and all the other fancy cath lab toys have but it takes time.

Aside from being able to percutanously place I do not see a huge benefit of a BiVAD Impella over traditional ECMO, especially as a bridge to transplant. I guess you can withdraw ventricular support independently if they RV recovers before the LV or vice versa.

@E tank Are you seeing Impella use more in the CT surgery world? I see it use in high risk PCI and cardiogenic shock increasing but I guess it can't really take the place of full support in the OR. Have you see the RVADs yet?

 

[E tank]

Aside from being able to percutanously place I do not see a huge benefit of a BiVAD Impella over traditional ECMO, especially as a bridge to transplant. I guess you can withdraw ventricular support independently if they RV recovers before the LV or vice versa.

@E tank Are you seeing Impella use more in the CT surgery world? I see it use in high risk PCI and cardiogenic shock increasing but I guess it can't really take the place of full support in the OR. Have you see the RVADs yet?

I think the big advantage of the Impella over ECMO is just that it is orders of magnitude less invasive and lower maintenance. I don't really know, maybe someone else does, but when there are issues of severe pulmonary HTN, an Impella catheter(s) would not be nearly as effective as ECMO.

I'm not really seeing it used more at all, in answer to your question. It may be an institutional culture thing, but IABP is still the go to device followed by ECMO. It's still less than 10 years old and there is an old saying in medicine that goes "be not the first, but be not the last" with regard to new stuff. Where I am, the jury is still out, given the other tools we have available.

 

[jedi1988]

I usually see Impellas for high risk PCI or refractory cardiogenic shock despite IABP therapy. The Impella RP (RVAD) is still in clinical trials so the only hospitals that have it are tertiary care facilities so you shouldn't see them sending those patients out.

 

[VFlutter]

The Impella RP (RVAD) is still in clinical trials so the only hospitals that have it are tertiary care facilities so you shouldn't see them sending those patients out.

That was my understanding as well however there are tertiary care facilities that are placing RPs that are not transplant capable so there still is that possibility. I am sure we request we received was a rare situation however still have to have plan for it.

 

[RocKetamine]

I've been trained to transport them but I've only had one flight request so far and we turned it down as we were on the way back from a nasty call and needed to restock.

They seem to be pretty popular in Central Texas and becoming more so in the Houston area.

 

[jedi1988]

Good point! Abiomed has some great courses on their website for training and it's free.

 

[Summit]

Took all the classes... and nobody wanted to put one in... and the one time the CCL was going to send the patient out with one I was going to thake them... then suddenly had to go to the OR... awww