Role of computed tomography and chest radiography in imaging of Impella heart pump and associated complications

Figures

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  Figure 1:. A 60-year-old male presenting with ST-elevation myocardial infarction with left anterior descending occlusion placed on Impella support for cardiogenic shock support with normal Impella positioning. (a) Frontal anteroposterior chest radiograph demonstrating normal positioning of Impella with red arrow marking the Impella outlet and yellow arrow marking the Impella port. (b) Coronal computed tomaography without contrast showing normal Impella positioning. Impella Cardiac Power inlet port indicated by the yellow arrow is about 35 mm from the aortic valve plane indicated by the red dashed line. For Impella 5.5 the inlet port should be 50 mm below the aortic valve plane.

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  Figure 2:. Computed tomography measurements between repositioned Impella vs. non-repositioned Impella devices. Box plot for CT measurements compared between those that had their Impella device re-positioned and those that did not require any repositioning.

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  Figure 3:. A 39-year-old male presenting with cardiac arrest with ST-elevation myocardial infarction with unstable hemodynamics placed on Impella support and found to have a high Impella positioning. (a) Chest radiograph of high positioned Impella. The outlet port, indicated by the red arrow, can be seen in the aortic arch indicating a malposition. (b) Associated sagittal computed tomography shows the outlet port in the aortic arch as indicated by the red arrow. The outlet of the device should be in the ascending aorta. (c) Associated coronal CT shows the inlet port at the level of the aortic valve plane as indicated by the red arrow. The pigtail end of the Impella is likely in the sub-mitral chordal apparatus. Echo reported as distance of 1.5 cm form the aortic valve plane confirming. A suboptimal position. The lack of opacification of the left ventricle on this contrast enhanced computed tomography angiography is due to reversed contrast flow direction in the aorta as the patient was also on a peripheral venoarterial extracorporeal membrane oxygenation (VA ECMO).

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  Figure 4:. A 35-year-old male presenting with non-ST-elevation myocardial infarction complicated by cardiogenic shock requiring Impella support and found to have a Low Impella positioning. Imaging modalities demonstrating low Impella positioning. (a) Chest radiograph shows the level of the carina indicated by the dotted line, while the arrow demarcates the Impella outlet below the carina. Significant distance between the carina and Impella outlet port should raise the suspicion for a lower Impella placement. (b) Coronal computed tomography image of the patient shows outlet port of the Impella device, indicated by the red arrow, very proximal to the marked level of the aortic valve plane which is marked by the dotted line. The inlet port is deep within the left ventricle.