Dr. Mark Grise Shares Advice on Access and Patient Management at Scripps 2015
The talk entitled “Tips and Tricks: Access and Patient Management” was given by Dr. Mark Grise, Medical Director of the Cardiac Catheterization Laboratory at Sacred Heart Hospital in Pensacola, Florida at the 26th annual 2015 Scripps Cardiovascular Interventions Conference on Tuesday, October 27, 2015. Dr. Grise’s talk was part of the pre-conference session titled “A New Procedure in the Cath Lab: Protected PCI Treating Complex and Higher-Risk Indicated Patients (CHIP).”
Before PCI—percutaneous coronary intervention—Dr. Grise recommends always doing a femoral angiogram to assess the tortuosity, stenosis, calcification, and size of the common femoral artery, which needs to be > 4.6 cm. The target zone for entry is the middle of the femoral head on the common femoral artery, which is seen under fluoroscopy in the anteroposterior projection. Before proceeding, Dr. Grise obtains access on the other side and takes a picture of the planned Impella side.
Upon entry, significant peripheral arterial disease can be a challenge and Dr. Grise always has a femoral emergency kit on hand for the contralateral blood vessel. It is possible that peripheral arterial disease in combination with iliac artery disease may require stenting before placement of the Impella. In these cases, Dr. Grise uses a 14F x 30 cm sheath to avoid putting the Impella through the newly stented blood vessel.
Once in position, the catheter is secured at the groin. Dr. Grise recommends physicians check their patients before going home, making sure the catheter is secure and no alarms are on—do not ignore suction alarms.
With regards to the heart pump, Dr. Grise notes that heart pumps can cause shear forces, which result in hemolysis in older cells in circulation—a situation which should clear in the first 24 hours. However, the occurrence of hemolysis may also indicate obstruction of inflow or the outflow is against the aortic valve. These conditions should be checked since hemolysis should not occur under normal conditions.
The purge solution for the heart pump works by keeping blood and denatured proteins out of the motor. This purge solution is recommended to be heparinized but can be used without heparin if clinically required.
For management of patients with heparin-induced thrombocytopenia, Dr. Grise uses bivalrudin. Before removing the Impella heart pump, Dr. Grise weans patients off pressors. He cautions physicians not to remove the Impella device too soon. Dr. Grise hopes these tips will improve physician skill and patient management.
The Impella 2.5 system is a temporary (<6 hours) ventricular support device indicated for use during high risk percutaneous coronary interventions (PCI) performed in elective or urgent, hemodynamically stable patients with severe coronary artery disease and depressed left ventricular ejection fraction, when a heart team, including a cardiac surgeon, has determined high risk PCI is the appropriate therapeutic option. Use of the Impella 2.5 in these patients may prevent hemodynamic instability which can result from repeat episodes of reversible myocardial ischemia that occur during planned temporary coronary occlusions and may reduce peri- and post-procedural adverse events.
Protected PCI and use of the Impella 2.5 is not right for every patient. Patients may not be able to be treated with Impella if they have certain pre-existing conditions, which a cardiologist can determine, such as: severe narrowing of the heart valve, severe peripheral artery disease, clots in blood vessels, or a replacement heart valve or certain heart valve deficiencies. Additionally, use of Impella has been associated with risks, including, but not limited to valvular and vascular injury, bleeding, and limb ischemia in certain patients. Learn more about the Impella devices’ approved indications for use, as well as important safety and risk information at www.protectedpci.com/indications-use-safety-information/.