Management of Anticoagulation with Impella® Percutaneous Ventricular Assist Devices and Review of New Literature

Succar, Luma; Sulaica, Elisabeth M; Donahue, Kevin; Wanat, Matthew A.

doi:10.1007/s11239-019-01837-6

Cited by 34 publications

(30 citation statements)

References 16 publications

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“…A recent publication reviewing the literature describing anticoagulation for Impella devices evaluated 6 articles that included 51 patients, with the largest study including 18 patients. 9 When comparing the RP with the OP, numerically more patients were able to achieve a stable therapeutic range as defined by 2 consecutive coagulation tests within goal range. The RP group also had more coagulation tests within the goal range and more patients with >50% of tests within goal range compared with the OP group.…”

Section: Discussionmentioning

confidence: 98%

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Anticoagulation Management for Impella Percutaneous Ventricular Assist Devices: An Analysis of a Single-Center Experience

2020

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Background: Impella devices offer temporary mechanical circulatory support for cardiogenic shock. The manufacturer recommends systemic anticoagulation with a target activated clotting time of 160 to 180 s but provides no guidance on how to manage both the heparinized purge solution and the additional intravenous heparin needed to reach this therapeutic range. Previous publications demonstrated a lack of standardization in heparin management for Impella devices. Objective: The purpose of this study was to compare the effectiveness and safety of 2 different heparin protocols for long-term Impella support. Methods: This single-center, retrospective study included adult patients on Impella support for greater than 24 hours. The primary end point was time to therapeutic range measured in hours, from time of implantation to the first of 2 consecutive measurements within the therapeutic range. Secondary end points included percentage of time in therapeutic range, rates of major bleeding, pump thrombosis, hemolysis, and nursing satisfaction. Results: There were 19 patients identified, with 7 using the original protocol and 12 using the revised protocol. Time to therapeutic range was similar between protocols (15.5 vs 12 hours, P = NS). Another 14 patients were managed with patient-specific protocols as a result of bleeding or physician preference. In total, 42% of all patients in this study experienced major bleeding. There were no confirmed thrombosis events. This study was limited by a small sample size. Conclusion and Relevance: Despite using different heparin protocols, outcomes and bleeding events were similar between groups. Future studies are needed to determine the optimal degree of anticoagulation necessary to reduce bleeding risk.

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Section: Discussionmentioning

confidence: 98%

Section: Discussionmentioning

confidence: 99%

Anticoagulation Management for Impella Percutaneous Ventricular Assist Devices: An Analysis of a Single-Center Experience

2020

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“…We are still limited to a data range of 48 hours to 4 days with dextrose-only purge solution, while some patients might require much longer durations of Impella therapy. 8 Despite the positive results in our case study, a lack of supporting literature outside of manufacturer recommended heparin limits direction on the efficacy and safety of nonheparin purge solutions.…”

Section: Discussionmentioning

confidence: 69%

Utilization of a Dextrose-Only Purge Solution for an LVAD in Patients With Suspected HIT: A Case Series

Bowers

Nowak

Bryan

et al. 2020

Journal of Pharmacy Practice

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The Impella devices are percutaneous intravascular ventricular assist devices indicated for use in patients with cardiogenic shock that occurs following acute myocardial infarction (MI) or open heart surgery. These devices must be used with a purge solution that contains heparin per manufacturer recommendation, which will prevent blood from reaching the motor causing pump thrombosis and mechanical failure. We describe the utilization of a dextrose-only purge solution plus systemic argatroban in 2 patients with suspected heparin-induced thrombocytopenia (HIT). Each case describes a patient with suspected HIT following Impella placement for cardiogenic shock post-MI that had an increased bleeding risk. In each case, pharmacy monitored and adjusted the patients’ argatroban, resulting in therapeutic anticoagulation without major bleeding or thrombotic events. These case reports demonstrate that use of a dextrose-only purge solution in the Impella device may be a safe and effective option when combined with systemic argatroban in patients with suspected or confirmed HIT who exhibit increased bleeding risk. Further research is needed to determine the optimal concentrations and duration of anticoagulation-free purge solution in these patients.

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“…In addition to heparin within the purge solution, systemic heparin or alternative anticoagulant may be administered for prophylaxis. 1,3 Our facility's standard protocol utilizes a purge solution using heparin (50 units/ml) in a 5% dextrose solution. Supplemental heparin is added on a case-by-case basis if necessary to maintain a goal aPTT of 50-60 s. Typically, 5000-10,000 units of heparin is given at the time of the procedure to have an ACT of 180-220 s. Heparin is completely reversed with protamine at the end of the procedure to ensure hemostasis.…”

Section: Commentarymentioning

confidence: 99%

“…To prevent thrombosis, the Impella device requires a purge line that traditionally uses a continuous heparin infusion. 1 Patient with contraindications to heparin requires alternative anticoagulation strategies. We describe the stepwise management of anticoagulation in a patient with multiple contraindications to a traditional heparin purge solution including the use of a bicarbonate-based purge solution (BBPS).…”

Section: Introductionmentioning

confidence: 99%

Use of a novel bicarbonate‐based Impella 5.5 purge solution in a coagulopathic patient

Simonsen¹,

Gunn

Malhotra³

et al. 2021

Journal of Cardiac Surgery

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The Impella 5.5 with Smart Assist (Abiomed) is a life-saving treatment option in acute heart failure which utilizes a continuous heparin purge solution to prevent thrombosis. In patients with contraindications to heparin, alternative anticoagulation strategies are required. We describe the stepwise management of anticoagulation in a coagulopathic patient with persistent cardiogenic shock following a coronary artery bypass procedure who underwent Impella 5.5 placement. A direct thrombin inhibitor-based purge solution was utilized while evaluating for heparin-induced thrombocytopenia. The use of a novel bicarbonate-based purge solution (BBPS) was successfully used due to severe coagulopathy. There were no episodes of pump thrombosis or episodes of severe bleeding on the BBPS and systemic effects of alkalosis and hypernatremia were minimal.

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Management of Anticoagulation with Impella® Percutaneous Ventricular Assist Devices and Review of New Literature

Cited by 34 publications

References 16 publications

Anticoagulation Management for Impella Percutaneous Ventricular Assist Devices: An Analysis of a Single-Center Experience

Anticoagulation Management for Impella Percutaneous Ventricular Assist Devices: An Analysis of a Single-Center Experience

Utilization of a Dextrose-Only Purge Solution for an LVAD in Patients With Suspected HIT: A Case Series

Use of a novel bicarbonate‐based Impella 5.5 purge solution in a coagulopathic patient

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