In this episode, I’ll discuss what Impella purge solution can be used if the patient has a contraindication to heparin.
The Impella device is a miniature ventricular assist device that is placed using a catheter into the left ventricle across the aortic valve. It works by pumping blood from left ventricle into the ascending aorta to increase overall systemic cardiac output. The device operates with a purge solution, creating positive pressure and preventing blood from entering the motor.
The purge solution is typically 25 units/mL of heparin in 5% dextrose. Because the purge solution eventually enters systemic circulation, a heparin-based solution is not desireable for use in many patients such as those with coagulopathy, bleeding, or a history of heparin-induced thrombocytopenia. In April 2022, the Food and Drug Administration approved utilization of bicarbonate-based purge solutions (BBPS) as an alternative to heparin for patients who are intolerant to heparin or in whom heparin is contraindicated.
A group of authors recently published in AJHP a case series of their patients who received treatment with an Imeplla device using a bicarb-based purge solution to describe the effects of such a solution.
They included 18 patients who received a bicarb-based purge solution for more than 24 hours, and included a 72 hour follow-up period after the bicarb purge solution was stopped.
The indications for using bicarb over heparin were as follows:
5 patients had coagulopathy
3 patients had known or suspected HIT
10 patients had major bleeding
Three patients had complications related to the pump as follows:
1 patient needed the pump to be exchanged
1 patient needed the pump removed
1 patient received alteplase for a suspected purge block
Of these 3 patients, two of them had received the bicarb-based purge solution for more than 21 days before experiencing a complication. The patients who received alteplase and whose pump was exchanged continued on bicarb-based purge solution without incident. The patient whose pump was removed had stable hemodynamics despite the device’s failure and therefore was discontinued off Impella.
The case series shows that bicarb-based purge solutions are a viable option for patients than cannot have heparin in their purge solution. Given that this data is a single center experience, the authors call for further research using bicarb-based purge solutions with the Impella device, especially in long-term use scenarios. The purge solution used for all patients in the case series was the manufacturer-recommended 25 mEq of sodium bicarbonate in 1 liter of 5% dextrose.
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