A new study highlights a novel fluoroscopic approach that could optimize the positioning of the Impella microaxial flow pump (Abiomed), reducing complications and improving outcomes for critically ill patients. Published online in JACC: Cardiovascular Interventions, the research suggests that using multiple fluoroscopic views during Impella implantation may help clinicians detect and correct malrotation earlier. “This new approach provides a more reliable method for positioning the Impella device, potentially improving outcomes for critically ill patients,” said lead researcher Alessandro Beneduce, MD, from the Heart Valve Center at IRCCS San Raffaele Hospital in Milan, Italy. Foreshortened imaging risk Traditionally, a single right anterior oblique (RAO) 30° fluoroscopic view is used for positioning the Impella pump. However, this method can result in foreshortened imaging, making it difficult to detect device malrotation. To address this, the researchers analyzed electrocardiographically gated cardiac computed tomography (CT) scans of 6 patients with cardiogenic shock supported by the Impella CP pump. They developed a sequential multi-view method incorporating a 3-chamber view (RAO 60° to caudal 45°), which evaluates depth and prevents impingement on the lateral heart wall. Complimenting this was a 4-chamber view (left anterior oblique 10° to cranial 60°), which confirms proper orientation relative to the septum and lateral wall. “A multiple-view approach involving sequential assessment of 3- and 4-chamber fluoroscopic views might enhance precision in Impella positioning, particularly when echocardiography is not promptly available,” the researchers said. “This technique might enable the early identification and correction of suboptimal device position.” Impella positioning Correct Impella placement is critical for adequate left ventricular unloading and to prevent complications such as interference with the mitral valve or papillary muscles. While current methods assess device depth using pressure and motor current waveforms, evaluating rotational alignment is challenging due to a lack of standardized fluoroscopic protocols. Device malrotation, where the pump inflow is positioned incorrectly away from the heart’s apex, has been linked with increased adverse events. The team concluded that this new approach may offer a more effective way to optimize positioning and improve patient outcomes. Source: Beneduce A, Baldetti L, Chieffo A, et al. A Novel Fluoroscopic Approach to Impella Microaxial Flow Pump Positioning. JACC Cardiovasc Interv. 2025. (Article in Press) Image Credit: Sebastian Kaulitzki – stock.adobe.com