Use of Tissue Plasminogen Activator Alteplase Purge Solution in an Impella 5.5 Heart Pump

Abstract

Standardized Impella purge solutions have traditionally consisted of 5-40% dextrose with or without unfractionated heparin as a means of anticoagulation. Such a solution serves to create a pressure barrier preventing entry of blood into the pump's motor housing with heparin providing adequate purge pathway patency in the event of this occurring. We present a case of tissue plasminogen activator (tPA, Activase) utilization in lieu of the recommended purge solution due to concern for thrombus formation of the purge pathway in a 51-year-old male with cardiogenic shock status-post Impella 5.5 heart pump placement for hemodynamic support while awaiting heart transplantation. The purge solution was successfully administered for 48 hours without complication and a reduction in average purge pressure with increase in purge flow rate was observed.

Outcomes of systemic bivalirudin and sodium bicarbonate purge solution for Impella 5.5

“…Although the exact incidence of thrombus formation leading to device malfunction remains unknown, several reports describe substituting standard purge fluid for a solution containing tPA, resulting in resolution of low purge flow in most cases 22 . While we observed a larger reduction in the time to tPA use than that observed by Tunney et al 25 it is difficult to make direct comparisons because patient characteristics are not controlled for, and because the purge solutions utilized between studies were different. Furthermore, there is no clear guidance for the optimal timing to administer a tPA‐based purge solution as salvage therapy.…”

Outcome of Patients Supported by Large Impella Systems After Re-implantation Due to Continued or Recurrent Need of Temporary Mechanical Circulatory Support

“…We performed an exchange of Impella 5+ in all patients with pump thrombosis. The utilization of tissue plasminogen activator (tPA) in the purge solution (0.04 mg/ml) has been recently introduced as an alternative to heparin ( 17 , 18 ). In our opinion, tPA is a valid therapy option for patients with diagnosed or suspected pump thrombosis, although a decision for initiation of tPA should be made cautiously and in an individual case-by-case fashion due to the strong fibrinolytic effect of tPA.…”

Optimizing anticoagulation for patients receiving Impella support

“…Several case reports and one case series describe substituting standard purge fluid for a solution containing alteplase (tPA) resulting in resolution of low purge flow in most cases. Based on these data, purge-delivered fibrinolytic therapy may be an option in selected patients if replacement of the Impella is not feasible, though it may not be a durable solution and systemic bleeding complications may occur 15,37 (Table 1).…”