Q6 / 110
Which scenario most strongly suggests isolated LV support will be insufficient?
Correct answer: B — Severe biventricular failure with elevated filling pressures on both sides
Severe failure of both ventricles may require BiVAD support because systemic flow remains limited by the RV despite LV support. A often tolerates isolated LV support. C does not automatically imply RV failure. D is not an MCS indication.
Board pearl: Match the number of supported ventricles to the physiology.
Severe failure of both ventricles may require BiVAD support because systemic flow remains limited by the RV despite LV support. A often tolerates isolated LV support. C does not automatically imply RV failure. D is not an MCS indication.
Board pearl: Match the number of supported ventricles to the physiology.
Q7 / 110
What is a major advantage of the Protek Duo over traditional surgically implanted RVAD cannulation?
Correct answer: B — It is inserted through the internal jugular vein, facilitating ambulation
Right internal jugular placement avoids femoral cannulation and can facilitate ambulation. It is also reasonable to assess the differences between Protek Duo and Impella RP. Both have been deemed safe and effective RVADs facilitating bridge to recovery; however, the practical difference in our population is the ability to add an oxygenator to the Protek Duo, resulting in V-P ECMO, which is not available with Impella RP. It does not require sternotomy for placement, does not unload the LV, and does not require an oxygenator unless gas-exchange support is also needed.
Board pearl: The practical difference in our population is the ability to add an oxygenator to the Protek Duo, resulting in V-P ECMO.
Right internal jugular placement avoids femoral cannulation and can facilitate ambulation. It is also reasonable to assess the differences between Protek Duo and Impella RP. Both have been deemed safe and effective RVADs facilitating bridge to recovery; however, the practical difference in our population is the ability to add an oxygenator to the Protek Duo, resulting in V-P ECMO, which is not available with Impella RP. It does not require sternotomy for placement, does not unload the LV, and does not require an oxygenator unless gas-exchange support is also needed.
Board pearl: The practical difference in our population is the ability to add an oxygenator to the Protek Duo, resulting in V-P ECMO.
Source(s): Agrawal et al. Clinical Outcomes in Acute Right Ventricular Failure with Percutaneous Right Ventricular Assist Devices: Impella RP and Protek Duo. Journal of the American College of Cardiology. 2021 May. 77(18):634.
Q8 / 110
Which finding is an absolute or near-absolute contraindication to a left-sided Impella?
Correct answer: B — Left ventricular thrombus
An LV thrombus may be disrupted by the Impella inlet and embolize systemically, making it an absolute or near-absolute contraindication to a left-sided Impella, alongside a mechanical aortic valve (the pigtail and inlet cannot safely cross a mechanical valve). Additional contraindications per the 2015 SCAI/ACC/HFSA/STS consensus and the 2023 ISHLT/HFSA guideline include moderate-to-severe aortic insufficiency, mitral stenosis, severe peripheral arterial disease precluding safe access, inability to tolerate systemic anticoagulation, severe atheromatous disease of the access vessel, and a ventricular septal defect (risk of worsening right-to-left shunt through the device pathway). A patent PFO is not itself a standard listed contraindication in major guidelines — the specific structural concern is a VSD. LVEF below 20% is commonly the reason support is needed rather than a contraindication, and severe tricuspid regurgitation is not itself a left-sided Impella contraindication.
Board pearl: Absolute/near-absolute contraindications to left-sided Impella: LV thrombus and mechanical aortic valve. Also consider severe AI, mitral stenosis, severe PAD, inability to anticoagulate, and VSD — not PFO, which is often confused with VSD in this context.
An LV thrombus may be disrupted by the Impella inlet and embolize systemically, making it an absolute or near-absolute contraindication to a left-sided Impella, alongside a mechanical aortic valve (the pigtail and inlet cannot safely cross a mechanical valve). Additional contraindications per the 2015 SCAI/ACC/HFSA/STS consensus and the 2023 ISHLT/HFSA guideline include moderate-to-severe aortic insufficiency, mitral stenosis, severe peripheral arterial disease precluding safe access, inability to tolerate systemic anticoagulation, severe atheromatous disease of the access vessel, and a ventricular septal defect (risk of worsening right-to-left shunt through the device pathway). A patent PFO is not itself a standard listed contraindication in major guidelines — the specific structural concern is a VSD. LVEF below 20% is commonly the reason support is needed rather than a contraindication, and severe tricuspid regurgitation is not itself a left-sided Impella contraindication.
Board pearl: Absolute/near-absolute contraindications to left-sided Impella: LV thrombus and mechanical aortic valve. Also consider severe AI, mitral stenosis, severe PAD, inability to anticoagulate, and VSD — not PFO, which is often confused with VSD in this context.
Source(s): 2015 SCAI/ACC/HFSA/STS Clinical Expert Consensus Statement on the Use of Percutaneous Mechanical Circulatory Support Devices in Cardiovascular Care. Rihal CS, Naidu SS, Givertz MM, et al. J Am Coll Cardiol. 2015;65(19):e7-e26. doi:10.1016/j.jacc.2015.03.036. | Bernhardt AM, Copeland H, Deswal A, Gluck J, Givertz MM. The ISHLT/HFSA Guideline on Acute Mechanical Circulatory Support. J Card Fail. 2023;29(3):304-374. doi:10.1016/j.cardfail.2022.11.003.
Q9 / 110
What is the primary purpose of the Impella purge solution?
Correct answer: B — Prevent blood from entering the pump motor
Purge solution protects the motor housing from blood entry and thrombosis. Heparin may contribute to anticoagulation, but A is not its primary purpose. C and D have no relationship to the purge system.
Board pearl: The purge protects the pump, not primarily the patient.
Purge solution protects the motor housing from blood entry and thrombosis. Heparin may contribute to anticoagulation, but A is not its primary purpose. C and D have no relationship to the purge system.
Board pearl: The purge protects the pump, not primarily the patient.
Q10 / 110
The SmartAssist feature on the Impella 5.5 detects malposition by monitoring which signal?
Correct answer: B — Pressure on opposite sides of a sensor membrane
SmartAssist compares LV and aortic pressure signals across a sensor system; similar pressures suggest both sensing locations are in the same chamber. A, C, and D are not the positional sensing mechanism.
Board pearl: Loss of distinct LV and aortic tracings should prompt a position check.
SmartAssist compares LV and aortic pressure signals across a sensor system; similar pressures suggest both sensing locations are in the same chamber. A, C, and D are not the positional sensing mechanism.
Board pearl: Loss of distinct LV and aortic tracings should prompt a position check.