How to Manage the Patient with
Hemodynamic Support: Trouble-Shooting
David M. Shavelle MD FACC FSCAI
Associate Clinical Professor
Keck School of Medicine at USC
Director, General Cardiology Fellowship
Director, Cardiac Catheterization Laboratory
Los Angeles County + USC Medical Center
Objectives
Discuss common issues related to IABP,
Tandem Heart and Impella:
1. Device insertion
2. Device malfunction
3. Device removal
“I embrace solutions, not excuses”
Jon Taffer, BAR RESCUE
Device Insertion
Case 1
68 yo male with ischemic cardiomyopathy, prior CABG, prior
PCI, EF 10% admitted with decompensated heart
failure. IABP placed in cath lab with initial
augmentation of 120 mm Hg on Dopamine 5
mcg/kg/min. The patient is transferred to the ICU and
the nurse calls stating IABP is ‘not working’ and is no
longer providing an augmentation of the BP.
The next best step in management would be:
1. Add Milrinone 0.25 mcg/kg/min
2. Increase Dopamine to 20 mcg/kg/min
3. Portable Chest Ray
4. Consider Impella Device
Case 1
68 yo male with ischemic cardiomyopathy, prior CABG, prior
PCI, EF 10% admitted with decompensated heart
failure. IABP placed in cath lab with initial
augmentation of 120 mm Hg on Dopamine 5
mcg/kg/min. The patient is transferred to the ICU and
the nurse calls stating IABP is ‘not working’ and is no
longer providing an augmentation of the BP.
The next best step in management would be:
1. Add Milrinone 0.25 mcg/kg/min
2. Increase Dopamine to 20 mcg/kg/min
3. Portable Chest Ray
4. Consider Impella Device
Movement of IABP
• Device placed on standby
• Advance based upon estimate of distance
• Recheck chest X ray
Optimal Device Placement: IABP
• Radio-opaque tip at
proximal portion of IABP
• Optimal position: tip distal
to left subclavian artery in
proximal descending aorta
• Common Issues
Unable to see on Xray
 over penetrate film
 palpate left radial and/or
brachial pulse
 may need fluroscopy
Ability to move IABP
 allow ‘slack’ at groin
Problem: Aorto-iliac Disease
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•
•
•
•
Indentify during initial arterial access
Difficult to place .025” wire
Access with floppy or hydrophilic wire (Benson,
Wholey, Magic Torque, Glide)  exchange
using catheter (glide catheter, JR4, MP, etc) for
IABP .025” wire
Consider angiography, PTA and stent
placement to facilitate IABP passage
If stent placed, fluroscopy essential during
IABP advancement through stent
Problem: No Femoral Access
•
•
•
•
Impella and TH not possible  IABP
Alternative access sites: left brachial & left
subclavian arteries
Axillary artery also possible
Described in heart failure/transplant
literature for prolonged access to keep
patients ambulatory (frequently with
conduits)
Left Brachial Artery Access
• 68 yo male, EF 20%,
ongoing CHF, severe
LM/LAD disease, Aortoiliac occlusion, refused
CABG
• Ht 6’ 6”, Wt 84 kg
• Ultrasound left brachial
artery: Ø 5 mm
• Punctured and 8F
sheath inserted for 50 cc
Mega IABP
• Removed at end of
case with manual
compression
Left brachial fossa with 50 cc Mega via sheath
Device Insertion: Tandem Heart
• Transseptal puncture: lost art, not trained during IC
fellowship  very difficult to achieve necessary skills
• Current fellows  partner with EP program for afib cases
• Puncturing the septum – 3 approaches
• Fluroscopic – anatomic landmarks
• ICE guided
• TEE guided
• Regardless of method: meticulous technique, go slow,
measure pressures during puncture (not done by majority
of EP doctors), use contrast to define anatomy
• Reference = Daoud E Heart Rhythm Vol 2 No 2 Feb 2005
Device Insertion: ICE Guidance
ICE catheter and BB needle
Clear tenting of IAS
Daoud E Heart Rhythm Vol 2 No 2 Feb 2005
Device Insertion: TEE Guidance
Clear tenting of mid IAS
LA cannulae in place
Anesthesia & Analgesia. 103(6):1412-1413, December 2006
Optimal Device Placement: TH
.035” Amplatzer wire
Mullins TS sheath
Standard wire = Amplatz ES
or SS or Amplatzer J wire
.025” Inoue wire
Additional support
Rarely, IAS needs to be
dilated with 4 mm
balloon to facilitate
cannulae placement
Optimal Device Placement: TH
Insert movie name =
JC8
Left Atrial Gram via
Mullins TS sheath
Insert movie name =
JC7
Tandem Heart 21 F venous
cannulae in left atrium
Optimal Device Placement: TH
• Radio-opaque markers on tip of venous cannulae
• Observe venous cannulae position
• Cannulae can move/entrain into the pulmonary vein – commonly
left upper pulmonary vein  low flow
PTA to Facilitate Impella Placement
• Very uncommon to need PTA if pre placement angiogram is done
• If stent is required – you must watch device pass stent under fluroscopy
Probable ‘posterior’ plaque not appreciated on AP Aortogram PTA of distal Ao and Right and Left Iliac Arteries with 9 and 10 mm Balloons
allowed placement of Impella Device via R CFA
Optimal Device Placement: Impella
•AL-1 and 0.035” J or straight wire to cross Aortic Valve  exchange for
Impella .018” wire  back load device and insert through 13 F sheath
RAO Projection
LAO Projection
Device Insertion Using Fluroscopic
and Angiographic Guidance
Optimal
Puncture
site
Rim
Catheter
forceps
Device Insertion Using Fluroscopic
and Angiographic Guidance
Insert movie name =
wells_2
Puncture at Mid CFA under
Angiographic Guidance
Insert movie name =
completion
Completion Angiogram:
No extravasation AND
Normal distal flow
Is Speed Important?
• If critically ill patient  IABP
• Impella and/or Tandem Heart for several elective cases 
high risk PCI
• Transition to ‘after hours’ and ‘emergent use’ once 2-3 cases
have been done successfully
• Always ask for help from 2nd operator and/or Senior Partner
Device Malfunction
Case 2
52 yo female with cardiogenic shock, s/p intubation, on
multiple pressors, presumed myocarditis, on IABP and
transitioned to emergent TH placement with initially
excellent flows. Now with falling flow rates. CXR
shows stable position of LA cannulae. HCT 28. Groins
without hematoma.
The most common reason for falling flow rates would be:
A. Inadequate volume
B. Hemolysis
C. Recovery of left ventricular function
Case 2
52 yo female with cardiogenic shock, s/p intubation, on
multiple pressors, presumed myocarditis, s/p TH
placement and initially with excellent flows. Now with
falling flow rates. CXR shows stable position of LA
cannulae. HCT 28. Groins without hematoma.
The most common reason for falling flow rates would be:
A. Inadequate volume
B. Hemolysis
C. Recovery of left ventricular function
TH Placement following IABP
IAPB in place. Left atrial angiogram via trans septal sheath to
define left atrial anatomy. Normal sized left atrium.
Optimize Hemodynamics
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•
•
For critically ill patients, the use of a Swan
Ganz Catheter can be helpful
Optimal filling pressures can often be difficult
to empirically determine
Most patients require higher filling pressures
than normal  for example, RAP 10 and
Wedge 20 mm Hg
Case 3
70 yo male with cardiogenic shock, s/p placement of
Impella Device via right femoral artery, HD#2, now
with low flows, dark urine and falling Hematocrit.
The next best step in management would be:
A. Device removal
B. Place IABP via contra-lateral femoral artery
C. Send plasma free hemoglobin, LDH and haptoglobin
Case 3
70 yo male with cardiogenic shock, s/p placement of
Impella Device via right femoral artery, HD#2, now
with low flows, dark urine and falling Hematocrit.
The next best step in management would be:
A. Device removal
B. Place IABP via contra-lateral femoral artery
C. Send plasma free hemoglobin, LDH and haptoglobin
Impella Device Related Hemolysis
ISAR-SHOCK
J Am Coll Cardiol 2008;52:1584–8
Device Removal
Device Removal: IABP
Manual hemostasis (‘Fellow Device’) = proximal and distal control
Device Removal: IABP with
Manual Hemostasis
Insert movie name = IMG_0737
Pre-Close Technique with 2 devices
10 o’clock
2 o’clock
IABP Device Removal: Additional Options
Remove 40 cc IABP via 8 F standard sheath  place 8 F
AngioSeal device using standard .035 J wire
Bleeding Events: Impella/Tandem Heart
Author/Year
Device
n
Sjauw/2009
USpella/2012
Burkhoff/2006
Seyfarth/2008
Impella 2.5
Impella 2.5
TH
TH
144
175
19
26
Thomas/2010
TH
37
Bleeding Requiring
Transfusion
5.5 %
9.7 %
42 %
PRBC 2.6±2.7 units
82 %
• All patients should have and active Type and Cross with blood available
• Working large bore peripheral or central line to give blood
Problem: Cardiac Arrest
• IABP
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Change to ‘internal mode’
Provides counter-pulsation at fixed rate
of 80 bpm
When stable, consider TVP and IABP
triggered to TVP
Correct acidosis, secondary issues
Problem: Cardiac Arrest
• Tandem Heart and Impella
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Continue support during CPR
Consider ‘light’ CPR
Confirm position of device when stable
Consider echocardiogram (TH) when stable
 pericardial effusion
Problem: IABP Balloon Rupture
•
Blood noted within balloon catheter by nursing
or alarms from lack of sufficient inflation
• Most commonly occurs after insertion and likely
related to adjacent vessel calcium
• Possibly related to insertion with damage to the
balloon from adjacent calcium  less likely
• IABP must be removed
– Is patient stable? Support with pressors
– Replace IABP via CL FA or consider an
alternative device
Problem: Loss of Distal Pulses
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Common for all devices
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Assess with physical examination
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TH (15/17 F) > Impella (13 F) >> IABP (8 F)
Color/temperature of leg/foot
Evidence of embolic event
Pulses by palpation and/or doppler
Baseline pulse exam essential
May require device removal
Unique Solutions to Limb Ischemia
• Antegrade SFA puncture with 4/5 F sheath
• Antegrade sheath connected to the retrograde
15/17 F TH sheath with short tubing segment
• ‘Auto’ perfusion of ischemic limb
• Can only be done with Tandem Heart device
Questions?