Difference between revisions of "Insertion of percutaneous ventricular assist device"

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{{Infobox surgical case reference
| anesthesia_type = GA vs. Regional vs. Local
| airway =
| lines_access = Large-bored PIV, arterial line
| monitors = Intraoperative transesophageal echocardiography (TEE) if GA
| considerations_preoperative =
| considerations_intraoperative =
| considerations_postoperative =
}}


Percutaneous ventricular assist device (pVADs) are temporary mechanical circulatory support devices that provide acute hemodynamic support.
=== Types of pVAD ===
# Impella Devices
## Left-sided
### Examples: Impella 2.5 (femoral), CP 5.0 (femoral), Impella 5.0 or 5.5 (axillary)
####Femoral access may be done under local anesthesia
####Axillary access often requires surgical cutdown and general anesthesia
### Catheter-based pumps inserted via femoral artery and pump blood from left ventricle into ascending aorta, providing up to 5 L/min of flow
## Right-sided
### Example: RP
### Catheter-based pumps inserted via femoral vein and pump blood from right atrium to the pulmonary artery
# Tandem Heart
## Continuous-flow centrifugal pump system that pumps blood from left atrium via a transseptal puncture to femoral artery, providing up to 5 L/min of flow
## May include ProtekDuo cannula for right ventricular support
=== Indications ===
* Cardiogenic shock (SCAI C-D stages)
* ECMO patients with left ventricular distention (ECPELLA)
* High risk PCI
=== Contraindications ===
* Biventricular failure
* High bleeding risk (inability to tolerate systemic anticoagulation)
* Left ventricular thrombus
* Aortic valve disease (moderate-severe aortic regurgitation, aortic stenosis, mechanical AVR)
* Aortic dissection
* Tamponade
* Severe peripheral artery disease
== Preoperative management ==
=== Patient evaluation<!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --> ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Neurologic
|
|-
|Cardiovascular
|
|-
|Pulmonary
|
|-
|Gastrointestinal
|
|-
|Hematologic
|
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}
=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> ===
* Pre-operative echocardiography to ensure no clots in left ventricle, adequate right ventricular function to receive post-pVAD insertion increased cardiac output
* Type and screen
=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> ===
* Arterial line set up
* Intraoperative transesopheageal echocardiography
* Near-infrared spectroscopy system (NIRs)
=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===
* Patients often have pacemakers or ICDs
** May need to contact electrophysiology to disable tachyarrhythmia therapy and place defibrillator pads on patient prior to procedure
** If pacer dependent, will need to be placed in DOO at set rate
=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===
== Intraoperative management ==
=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===
* Large peripheral IVs
* Arterial line on opposite side as axillary artery that will be used for Impella insertion
* Pulmonary artery catheter
* Intraoperative transesophageal echocardiography
=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===
=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===
Supine, arms out
=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===
* Hemodynamic management
* Adequate anticoagulation
** Heparin to achieve goal ACT of 250-300 seconds
* Intraoperative TEE to exclude contraindications (e.g. LV thrombus, aortic valve pathology) and guide device positioning
=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===
== Postoperative management ==
=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===
=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===
=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===
* Limb ischemia
* Vascular injury
* Bleeding
* Hemolysis
* Acute kidney injury
* Thromboembolism, air embolism
* Cardiac perforation
* Valve injury
* Device malposition
* Cardiac tamponade
== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==
{| class="wikitable"
|+
!
!Impella 5.0, 5.5
!Impella 2.5, CP
|-
|Unique considerations
|Axillary access
Often GA, but may be done under regional
|Femoral access
Often local or regional anesthesia
|-
|Position
|
|
|-
|Surgical time
|
|
|-
|EBL
|
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}
== References ==
# Rihal CS, Naidu SS, Givertz MM, et al. 2015 SCAI/ACC/HFSA/STS Clinical Expert Consensus Statement on the Use of Percutaneous Mechanical Circulatory Support Devices in Cardiovascular Care: Endorsed by the American Heart Assocation, the Cardiological Society of India, and Sociedad Latino Americana de Cardiologia Intervencion; Affirmation of Value by the Canadian Association of Interventional Cardiology-Association Canadienne de Cardiologie d'intervention. ''J Am Coll Cardiol''. 2015;65(19):e7-e26. doi:10.1016/j.jacc.2015.03.036
# Bernhardt AM, Copeland H, Deswal A, et al. The International Society for Heart and Lung Transplantation/Heart Failure Society of America Guideline on Acute Mechanical Circulatory Support. ''J Card Fail''. 2023;29(3):304-374. doi:10.1016/j.cardfail.2022.11.003
[[Category:Surgical procedures]]

Latest revision as of 15:48, 13 September 2025

Insertion of percutaneous ventricular assist device
Anesthesia type

GA vs. Regional vs. Local

Airway
Lines and access

Large-bored PIV, arterial line

Monitors

Intraoperative transesophageal echocardiography (TEE) if GA

Primary anesthetic considerations
Preoperative
Intraoperative
Postoperative
Article quality
Editor rating
Unrated
User likes
0

Percutaneous ventricular assist device (pVADs) are temporary mechanical circulatory support devices that provide acute hemodynamic support.

Types of pVAD

  1. Impella Devices
    1. Left-sided
      1. Examples: Impella 2.5 (femoral), CP 5.0 (femoral), Impella 5.0 or 5.5 (axillary)
        1. Femoral access may be done under local anesthesia
        2. Axillary access often requires surgical cutdown and general anesthesia
      2. Catheter-based pumps inserted via femoral artery and pump blood from left ventricle into ascending aorta, providing up to 5 L/min of flow
    2. Right-sided
      1. Example: RP
      2. Catheter-based pumps inserted via femoral vein and pump blood from right atrium to the pulmonary artery
  2. Tandem Heart
    1. Continuous-flow centrifugal pump system that pumps blood from left atrium via a transseptal puncture to femoral artery, providing up to 5 L/min of flow
    2. May include ProtekDuo cannula for right ventricular support

Indications

  • Cardiogenic shock (SCAI C-D stages)
  • ECMO patients with left ventricular distention (ECPELLA)
  • High risk PCI

Contraindications

  • Biventricular failure
  • High bleeding risk (inability to tolerate systemic anticoagulation)
  • Left ventricular thrombus
  • Aortic valve disease (moderate-severe aortic regurgitation, aortic stenosis, mechanical AVR)
  • Aortic dissection
  • Tamponade
  • Severe peripheral artery disease

Preoperative management

Patient evaluation

System Considerations
Neurologic
Cardiovascular
Pulmonary
Gastrointestinal
Hematologic
Renal
Endocrine
Other

Labs and studies

  • Pre-operative echocardiography to ensure no clots in left ventricle, adequate right ventricular function to receive post-pVAD insertion increased cardiac output
  • Type and screen

Operating room setup

  • Arterial line set up
  • Intraoperative transesopheageal echocardiography
  • Near-infrared spectroscopy system (NIRs)

Patient preparation and premedication

  • Patients often have pacemakers or ICDs
    • May need to contact electrophysiology to disable tachyarrhythmia therapy and place defibrillator pads on patient prior to procedure
    • If pacer dependent, will need to be placed in DOO at set rate

Regional and neuraxial techniques

Intraoperative management

Monitoring and access

  • Large peripheral IVs
  • Arterial line on opposite side as axillary artery that will be used for Impella insertion
  • Pulmonary artery catheter
  • Intraoperative transesophageal echocardiography

Induction and airway management

Positioning

Supine, arms out

Maintenance and surgical considerations

  • Hemodynamic management
  • Adequate anticoagulation
    • Heparin to achieve goal ACT of 250-300 seconds
  • Intraoperative TEE to exclude contraindications (e.g. LV thrombus, aortic valve pathology) and guide device positioning

Emergence

Postoperative management

Disposition

Pain management

Potential complications

  • Limb ischemia
  • Vascular injury
  • Bleeding
  • Hemolysis
  • Acute kidney injury
  • Thromboembolism, air embolism
  • Cardiac perforation
  • Valve injury
  • Device malposition
  • Cardiac tamponade

Procedure variants

Impella 5.0, 5.5 Impella 2.5, CP
Unique considerations Axillary access

Often GA, but may be done under regional

Femoral access

Often local or regional anesthesia

Position
Surgical time
EBL
Postoperative disposition
Pain management
Potential complications

References

  1. Rihal CS, Naidu SS, Givertz MM, et al. 2015 SCAI/ACC/HFSA/STS Clinical Expert Consensus Statement on the Use of Percutaneous Mechanical Circulatory Support Devices in Cardiovascular Care: Endorsed by the American Heart Assocation, the Cardiological Society of India, and Sociedad Latino Americana de Cardiologia Intervencion; Affirmation of Value by the Canadian Association of Interventional Cardiology-Association Canadienne de Cardiologie d'intervention. J Am Coll Cardiol. 2015;65(19):e7-e26. doi:10.1016/j.jacc.2015.03.036
  2. Bernhardt AM, Copeland H, Deswal A, et al. The International Society for Heart and Lung Transplantation/Heart Failure Society of America Guideline on Acute Mechanical Circulatory Support. J Card Fail. 2023;29(3):304-374. doi:10.1016/j.cardfail.2022.11.003

Top contributors: Chris Rishel and Katherine Lee

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