Abiomed Impella Manuel D'utilisation page 22

FOUR IMPELLA CATHETER POSITIONS
There are four Impella Catheter positions you are likely to encounter when
examining echocardiograms from patients supported with the Impella
Catheter include:
1-Correct Impella Catheter position
2-Impella Catheter too far into the left ventricle
3-Impella Catheter inlet in the aorta
4-Impella Catheter in papillary muscle
The following pages describe each situation. Figures 3−6 illustrate
transesophageal echocardiograms (TEE). Figures 7−10 illustrate
transthoracic echocardiograms (TTE) of each situation.
1−CORRECT IMPELLA CATHETER POSITION
For optimal positioning of the Impella Catheter, the inlet area of the
catheter should be 3.5 cm below the aortic valve annulus and well away
from papillary muscle and subannular structures. The outlet area should be
well above the aortic valve. If the Impella Catheter is correctly positioned,
echocardiography will likely show the following, as depicted in Figure 1
and 3 (TEE) and Figures 2 and 7 (TTE):
• Catheter inlet area 3.5 cm below the aortic valve
• Catheter outlet area well above the aortic valve
(frequently not visible on TEE or TTE images)
• Catheter angled toward the left ventricular apex away from the heart
wall and not curled up or blocking the mitral valve
2−IMPELLA CATHETER TOO FAR IN LEFT VENTRICLE
If the Impella Catheter is positioned too far into the left ventricle, the
patient will not receive the benefit of Impella Catheter support. Blood
will enter the inlet area and exit the outlet area within the ventricle.
Obstruction of the Impella Catheter inlet area can lead to increased
mechanical forces on blood cell walls and subsequent hemolysis, which
often presents as dark or blood-colored urine. If the Impella Catheter is too
far into the left ventricle, echocardiography will likely show the following,
as depicted in Figure 4 (TEE), and Figure 8 (TTE):
• Catheter inlet area more than 4 cm below the aortic valve
• Catheter outlet area across or near the aortic valve
3−IMPELLA CATHETER INLET IN THE AORTA
If the inlet area of the Impella Catheter is in the aorta, the patient will
not receive the benefit of Impella Catheter support. The catheter will pull
blood from the aorta rather than the left ventricle. In addition, suction is
possible if the inlet area is against the wall of the aorta or valve sinus. If
the inlet area of the Impella Catheter is in the aorta, echocardiography will
likely show the following, as depicted in Figure 5 (TEE), Figure 9 (TTE):
• Catheter inlet area in aorta or near the aortic valve
• Catheter pigtail too close to the mitral valve
4−IMPELLA CATHETER IN PAPILLARY MUSCLE
If the inlet area of the Impella Catheter is too close to or entangled in the
papillary muscle and/or subannular structures surrounding the mitral valve,
it can affect mitral valve function and negatively impact catheter flow.
If the inlet area of the catheter is lodged adjacent to the papillary muscle,
the inflow may be obstructed−resulting in suction alarms. This positioning
is also likely to place the outlet area too close to the aortic valve, which
can cause outflow at the level of the aortic valve, with blood streaming
back into the ventricle−resulting in turbulent flow and hemolysis.
If the Impella Catheter is too close to or entangled in the papillary muscle,
echocardiography will likely show the following, as depicted in Figure 6
(TEE) and Figure 10 (TTE):
• Catheter pigtail in papillary muscle
• Catheter inlet area more than 4 cm below the aortic valve or lodged
between papillary muscle and the myocardial wall
• Catheter outlet area too close to the aortic valve
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TRANSESOPHAGEAL AND TRANSTHORACIC
ECHOCARDIOGRAPHIC IMAGES
The following images depict trans-esophageal echocardiographic (TEE)
and transthoracic echocardiographic (TTE) images of four Impella Catheter
positions.
Four Transesophageal Echocardiographic (TEE) images
Figure 3. Correct Impella Catheter Position (TEE)
• Catheter inlet area 3.5 cm below the aortic valve
• Catheter outlet area well above the aortic valve
• Catheter angled toward the left ventricular apex away from the heart
wall and not curled up or blocking the mitral valve
Figure 4. Impella Catheter Too Far into Left Ventricle (TEE)
• Catheter inlet area more than 4 cm below the aortic valve
• Catheter outlet area across or near the aortic valve
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