Journal of Cardiothoracic and Vascular Anesthesia 33 (2019) 26632668

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Journal of Cardiothoracic and Vascular Anesthesia

journal homepage: www.jcvaonline.com

Special Article
Transesophageal Echocardiography for Impella
Placement and Management
Jerome Crowley, MD*, Brett Cronin, MDy,
Michael Essandoh, MDz, David D’Alessandro, MD1 x,
Ken Shelton, MD*, Adam A. Dalia, MD, MBA*,
*
Department of Anesthesiology, Pain Medicine, and Critical Care, The Massachusetts General Hospital,
Harvard Medical School, Boston, MA
y
Department of Anesthesiology, University of California San Diego, UCSD School of Medicine, San Diego, CA
z
Department of Anesthesiology, The Ohio State University Medical Center, Columbus, OH
x
Department of Cardiothoracic Surgery, The Massachusetts General Hospital, Harvard Medical School,
Boston, MA

Key Words: transesophageal echocardiography; TEE; intraoperative echocardiography; Impella; percutaneous left ventricular assist device; procedural
TEE guidance

ACUTE CARDIOGENIC SHOCK is a common problem
encountered by cardiac anesthesiologists. Current methods of
treatment include pharmacologic and mechanical circulatory
support (MCS). MCS is used for temporary or long-term treat-
ment of cardiogenic shock. Temporary MCS is used as a bridge
to myocardial recovery, a bridge to a more durable therapy
(durable MCS or heart transplantation), or a bridge to decision-
making.1 Temporary MCS is becoming more common in car-
diogenic shock in multiple scenarios including postcardiotomy
shock, high-risk percutaneous cardiac intervention, acute
decompensated heart failure, and ventricular tachycardia abla-
tion, and for percutaneous venting of the left ventricle during
peripheral venoarterial extracorporeal membrane oxygen-
ation.2,3 The left-sided Impella (Abiomed Inc., Danvers, MA)
heart pump is a commonly used temporary MCS device. This
review describes the Impella and provides guidance in the use
of transesophageal echocardiography in its placement. Informa-
tion about troubleshooting deteriorating hemodynamics when
an Impella is being used is provided as well.
1
Address reprint requests to Adam A. Dalia, MD, MBA, Division of Cardiac
Anesthesiology, Department of Anesthesia, Critical Care and Pain Medicine,
The Massachusetts General Hospital, Harvard Medical School, 55 Fruit St,
Boston, MA 02114.
E-mail address: aadalia@mgh.harvard.edu (A.A. Dalia).
Model Types, Features, and Indications
The Impella heart pump is a miniaturized ventricular assist
device that consists of an Archimedes screw pump inserted
across the aortic valve and provides continuous drainage of
blood from the left ventricle and reinfuses the blood into the
ascending aorta regardless of left ventricular contractility.
There are several types of Impella devices that vary based on
insertion site and maximal flow rate. The Impella 2.5 (Fig 1)
and the Impella CP are placed most commonly percutaneously
via the femoral artery and are approved for a maximum dura-
tion of use of 4 days; maximum flow rates for the Impella 2.5
and Impella CP are 2.5 L/min and 3.3 L/min, respectively.4
The Impella 5.0 is placed most often by surgical cutdown to
an artery and the Impella LD is placed directly into the aorta
during surgical exposure, and they are approved for a maxi-
mum duration of use of 6 days with maximum flow rates of
5 L/min.5 For right ventricular failure, the Impella RP can be
used to drain blood from the right ventricle and reinfuse into
the pulmonary artery to aid right ventricular recovery but is
not the focus of this article.
Despite differences in insertion technique and maximal
blood flow support provided by the different Impellas, the final
placement of the device is very similar. The device consists of

https://doi.org/10.1053/j.jvca.2019.01.048
1053-0770/Ó 2019 Elsevier Inc. All rights reserved.
2664 J. Crowley et al. / Journal of Cardiothoracic and Vascular Anesthesia 33 (2019) 26632668
Fig 1. Impella 2.5 device labeled.
3 major components: a screw pump that provides continuous
blood flow, a flexible pigtail that extends from the distal end
of the pump, and a drive line that connects the motor to the
controller outside the patient. The pump has to be positioned
appropriately to function properly; that is, the inlet of the
pump must be in the left ventricle and the outlet must be in the
ascending aorta. The initial placement of the Impella com-
monly is done under fluoroscopic and transesophageal
echocardiography guidance; additionally, troubleshooting a
malfunctioning Impella heart pump is a scenario where TEE
commonly is used. Although fluoroscopy can be helpful in
identifying the general location of the Impella in vitro, it can-
not detect its position in relation to important anatomic cardiac
landmarks such as the subvalvular apparatus of the mitral
valve or the distance from the aortic valve to the Impella inlet;
thus, TEE is a valuable tool for placement.6
It is also important that anesthesiologists have an under-
standing of the indications and contraindications for Impella
heart pump placement. Indications for the Impella heart pump
include reversible myocardial ischemia, acute severe left ven-
tricular failure, and ventricular tachycardia ablation, or use
during high-risk percutaneous cardiac intervention in patients
with severe coronary artery disease and reduced ejection frac-
tions.4 Biventricular failure, significant aortic insufficiency,
left ventricular thrombus, mechanical aortic valve, and large
intracardiac shunts may represent contraindications to Impella
heart pump placement and at the very least require additional
discussion with the proceduralist, because other types of
mechanical support may be suited better; a full list of contrain-
dications can be found in Table 1.4
TEE Guidance for Impella Heart Pump Placement
Implantation of the Impella heart pump is dictated by the
model (2.5, 5.0, CP) as described above. For the Impella 2.5,
5.0, and CP, the vessel of choice (commonly femoral or axil-
lary) is accessed and a sheath is placed. Next, a combination
of wires and catheters are used to cross the aortic valve to
serve as a conduit for the Impella heart pump. The descending
thoracic aorta should be interrogated in the aortic short and
long axes to confirm wire placement in the aorta as well as to
rule out aortic dissection from placement. Next, the mideso-
phageal aortic valve long-axis view can be used to visualize
the wire crossing the aortic valve and entering the left ventri-
cle. If the wire is in too deep in the left ventricular cavity, it
may cause ventricular arrhythmias; it is also important to
avoid having the wire cross the mitral valve, as inappropriate
wire placement will lead to inappropriate Impella placement.
In the case of mitral valve tethering, the guidewire will need to
be withdrawn and repositioned. Increases in aortic insuffi-
ciency (significant increase may represent aortic valve injury)
and changes in mitral valve function (the wire may be interfer-
ing with the subvalvular apparatus) should be monitored and
discussed with the proceduralists to reduce complications.
Once the wire is seen crossing the aortic valve, a midesopha-
geal short-axis view of the aortic valve can be used to rule out
perforation or significant tethering of the aortic leaflets, as the
wire will need to be withdrawn and repositioned.7 Images of the
ascending aorta and aortic arch should be obtained to rule out fur-
ther aortic dissection. After the wire is confirmed to be in the
proper location, the proceduralist then will place the Impella heart
pump over the wire; at this point, the best view to guide place-
ment is the midesophageal aortic valve long-axis view. If there is
trouble advancing the device, views of the descending thoracic
aorta and the aortic arch should be obtained to aid in trouble-
shooting, because the Impella heart pump may be stuck in a
branch vessel or may be kinking the wire upon itself. After the
device is visualized across the aortic valve, the wire is withdrawn
and final appropriate positioning confirmed by TEE. The pigtail
at the end of the motor is not always visible on TEE imaging,
but attempts to locate it in the midesophageal aortic valve
long-axis view can be helpful to ensure it is not abutting the
Table 1
Left-Sided Impella (2.5, 5.0, CP) Contraindications
Biventricular failure
Cardiac tamponade
Left ventricular rupture
Mechanical aortic valve
Mural thrombus in left ventricle
ASD or VSD
Severe aortic insufficiency
Aortic dissection
Abbreviations: ASD, atrial septal defect; VSD, ventricular septal defect.
 J. Crowley et al. / Journal of Cardiothoracic and Vascular Anesthesia 33 (2019) 26632668
intraventricular septum (increased risk of arrhythmias) or entan-
gling in the subvalvular apparatus of the mitral valve8 (Video 1).
The inlet to the motor, which is visualized as a teardrop shape
in the midesophageal aortic valve long-axis view, should be in
the left ventricle 3.5 cm from the aortic valve (Fig 2). Color and
spectral Doppler imaging can be helpful in identifying the loca-
tion of the inlet, as can 3D echocardiography (Video 2, Fig 3).
Once the inlet is seen in the appropriate position, then the outlet
of the motor in the ascending aorta also can be visualized in the
midesophageal long-axis view with the aid of color Doppler
(Video 3, Fig 4). The transgastric long- or short-axis view is
also helpful to confirm appropriate positioning of the Impella
heart pump in the ventricle as well as to verify further no entan-
glement with the mitral valve apparatus (Video 4, Fig 5). Proper
positioning includes the Impella heart pump curved away from
the mitral valve facing the left ventricular apex.
After the Impella heart pump is identified as being in the cor-
rect position, the function of the mitral valve and aortic valve
again should be interrogated (Video 5). Color Doppler interro-
gation of the mitral valve to evaluate for the presence of or
worsening of mitral regurgitation related to device malposition
is useful; attention should be paid to any leaflet tethering that
may be owing to the Impella heart pump.9 The aortic valve is
difficult to image owing to device artifact; however, severe aor-
tic insufficiency can be suggestive of valve injury, so visualiz-
ing the device crossing the aortic valve in short axis and
observing leaflet motion are helpful (Video 6). The aorta should
be imaged at the end of device placement to ensure further no
iatrogenic dissection occurred. The pericardium also should be
assessed for any evidence of a new pericardial effusion, which
may represent ventricular perforation. The correct Impella heart
pump final position is described in Table 2.
Fig 2. Midesophageal long-axis view of Impella device. LA, left atrium; LV, left ventricle.
2665
Troubleshooting
It is important to remember that cardiogenic shock is a
dynamic process that is highly dependent on the current state
of biventricular function, volume status, and adjunctive phar-
macologic therapy, and TEE can be used to verify some of
these acute changes. A common evaluation involves patients
who are failing MCS with evidence of worsening multiorgan
perfusion. Using a midesophageal 4-chamber view, the anes-
thesiologist can observe for new causes of shock, such as acute
right ventricular failure. Interventricular septal position is also
an important indicator of optimal Impella heart pump place-
ment and function and should be interrogated. In the setting of
a well-functioning Impella, the interventricular septum should
be close to midline on TEE evaluation. Deviation of the inter-
ventricular septum to the right implies worsening left ventricu-
lar decompression that can be treated with increasing the
Impella pump speed and/or inotropes. Deviation of the inter-
ventricular septum to the left implies inadequate filling of the
left ventricle, which may be owing to right ventricular dys-
function (treated with inotropes or right ventricular support) or
suctioning of the left ventricle by high Impella pump speed
and can be treated by reducing the Impella pump speed.
New valvular lesions (aortic or mitral) detected on TEE may
represent iatrogenic injury from the Impella device and may
provide an explanation for the patient’s worsening status.
New-onset severe mitral regurgitation could be owing to sub-
valvular apparatus injury from device migration. Ventricular
arrhythmias commonly are owing to irritation of the ventricu-
lar septum by migration of the Impella, and position should be
verified as described above. Improved left ventricular contrac-
tility also can cause increased ventricular ectopy or result in
2666 J. Crowley et al. / Journal of Cardiothoracic and Vascular Anesthesia 33 (2019) 26632668

Fig 3. 3D midesophageal long-axis view of Impella device.

arrhythmias owing to device abutment of the ventricular sep- into the aorta will result in a lack of left ventricular support
tum. Advancement of the Impella too far into the left ventricle (the ventricle will not be unloaded) despite adequate flows,
may result in arrhythmias or direct myocardial injury causing thus making TEE guidance crucial during the manipulation
left ventricular puncture. Excessive withdrawal of the device of the Impella heart pump.

Fig 4. Midesophageal long-axis view of Impella device outlet with color Doppler. LA, left atrium; LV, left ventricle.
 J. Crowley et al. / Journal of Cardiothoracic and Vascular Anesthesia 33 (2019) 26632668
Fig 5. Transgastric midpapillary view with x-plane of Impella device free from papillary or subvalvular mitral apparatus. LV, left ventricle.
Table 2
Correct Position of the Impella and Corresponding TEE Views
Device inlet 3.5 cm below the aortic valve (midesophageal aortic valve
long-axis view)
Device outlet above the aortic valve (midesophageal aortic valve long-axis
view)
Device angled away from the mitral valve toward the left ventricular apex
(transgastric long-axis left ventricular view or midesophageal aortic valve
long-axis view)
Abbreviations: TEE, transesophageal echocardiography.
Table 3
Improper Positions of the Impella Device
Device too far into left ventricle (inlet >3.5 cm from aortic valve or outlet
across the aortic valve)
Outlet too far into ascending aorta (outlet area well above the aortic valve)
Device pigtail in the subvalvular apparatus of the mitral valve or papillary
muscle
Device angled away from the left ventricular apex
Although less common, suction events may occur if the ven-
tricle is decompressed excessively owing to improved native
ventricular function, a sign that the patient no longer may need
ventricular support with the Impella. Although not diagnosed
by TEE but rather laboratory findings, extended use of the
Impella heart pump also can lead to anemia or hemolysis, as is
seen with durable left ventricular assist devices.
Changes in patient status or device function perioperatively
should prompt investigation via TEE, as this is commonly a
2667
dynamic process affected by the level of anesthesia, volume
shifts, and pharmacologic intervention (Table 3). Finally, TEE
is useful during the MCS weaning process and may reveal
evidence of myocardial recovery.
Conclusion
Temporary MCS devices such as the Impella are becoming
more common owing to benefits in decreased myocardial oxy-
gen consumption compared with pharmacologic support.10 It is
critical that cardiac anesthesiologists are familiar with the func-
tion of these devices as well as the important role that TEE
plays in placing and managing these devices. As these devices
mature, more procedures may be done with Impella heart pump
support, particularly temporary support for high-risk patients.
Understanding how to guide placement and troubleshoot these
devices using echocardiography certainly will be a skill set
required of cardiac anesthesiologists in the future.
Supplementary materials
Supplementary material associated with this article can be
found in the online version at doi:10.1053/j.jvca.2019.01.048.
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