Q16 / 110
After two weeks of Impella 5.5 support, a patient has had minimal native LV recovery but still needs ongoing isolated left-sided circulatory support. Which next strategy is most appropriate?
Correct answer: C — Durable LVAD implantation
If a patient has had adequate temporary left-sided support with minimal recovery and still needs durable isolated LV assistance, transition to durable LVAD is the most appropriate next step. Impella CP would be a downgrade in support, Impella RP supports the wrong ventricle, and femoral VA-ECMO adds unnecessary cardiopulmonary support unless hypoxemia, refractory collapse, or major biventricular failure is also present. This question was changed per colleague feedback from an Impella-removal temporary-LVAD configuration question to a minimal-recovery-after-Impella-5.5 transition-to-durable-LVAD question.
Board pearl: When prolonged temporary LV support reveals minimal recovery, the decision often shifts from rescue physiology to durable strategy selection.
If a patient has had adequate temporary left-sided support with minimal recovery and still needs durable isolated LV assistance, transition to durable LVAD is the most appropriate next step. Impella CP would be a downgrade in support, Impella RP supports the wrong ventricle, and femoral VA-ECMO adds unnecessary cardiopulmonary support unless hypoxemia, refractory collapse, or major biventricular failure is also present. This question was changed per colleague feedback from an Impella-removal temporary-LVAD configuration question to a minimal-recovery-after-Impella-5.5 transition-to-durable-LVAD question.
Board pearl: When prolonged temporary LV support reveals minimal recovery, the decision often shifts from rescue physiology to durable strategy selection.
Q17 / 110
Which feature distinguishes the HeartMate 3 from previous durable LVAD generations?
Correct answer: B — Fully magnetically levitated centrifugal pump with an artificial pulse
HeartMate 3 is a fully magnetically levitated centrifugal continuous-flow pump with an artificial pulse. Previous LVAD generations had increased rates of both severe bleeding and stroke. The HMII is a continuous-flow pump delivered by a rotor suspended in the blood flow through a mechanical bearing, while the HMIII is a smaller continuous-flow pump with the rotor suspended in the blood flow using a noncontact design through magnetic levitation. This lack of contact with mechanical bearings decreases risk of thrombus formation and decreases overall stroke rate.
Board pearl: The HMIII uses a noncontact design through magnetic levitation, decreasing thrombus formation and overall stroke rate.
HeartMate 3 is a fully magnetically levitated centrifugal continuous-flow pump with an artificial pulse. Previous LVAD generations had increased rates of both severe bleeding and stroke. The HMII is a continuous-flow pump delivered by a rotor suspended in the blood flow through a mechanical bearing, while the HMIII is a smaller continuous-flow pump with the rotor suspended in the blood flow using a noncontact design through magnetic levitation. This lack of contact with mechanical bearings decreases risk of thrombus formation and decreases overall stroke rate.
Board pearl: The HMIII uses a noncontact design through magnetic levitation, decreasing thrombus formation and overall stroke rate.
Source(s): Mehra et al. A Fully Magnetically Levitated Left Ventricular Assist Device—Final Report. The New England Journal of Medicine. 2019 Mar;380:1618-1627.
Q18 / 110
Which feature favors a percutaneous Protek Duo over a surgically cannulated Rotaflow RVAD?
Correct answer: B — Bedside removal without repeat sternotomy
Percutaneous Protek Duo support can often be removed without repeat sternotomy. A overstates typical flow. C is false because hemolysis and pulmonary complications can occur. D is wrong because the device supports the RV.
Board pearl: Protek Duo is attractive for delayed or percutaneous RV support.
Percutaneous Protek Duo support can often be removed without repeat sternotomy. A overstates typical flow. C is false because hemolysis and pulmonary complications can occur. D is wrong because the device supports the RV.
Board pearl: Protek Duo is attractive for delayed or percutaneous RV support.
Q19 / 110
Which echocardiographic finding best suggests balanced temporary BiVAD flow?
Correct answer: C — Interventricular septum near the midline
A midline interventricular septum best suggests balanced temporary BiVAD flow. Of note, both devices in BiVAD insertions can result in recirculation due to pulmonic and aortic insufficiency. The flows calibrated can be deceiving; however, we want to avoid over circulation of the pulmonary vasculature due to risk of severe pulmonary edema and pulmonary hemorrhage. Complete LV collapse or marked septal deviation implies imbalance rather than true balance.
Board pearl: The flows calibrated can be deceiving in BiVAD insertions, especially when pulmonic or aortic insufficiency allows recirculation.
A midline interventricular septum best suggests balanced temporary BiVAD flow. Of note, both devices in BiVAD insertions can result in recirculation due to pulmonic and aortic insufficiency. The flows calibrated can be deceiving; however, we want to avoid over circulation of the pulmonary vasculature due to risk of severe pulmonary edema and pulmonary hemorrhage. Complete LV collapse or marked septal deviation implies imbalance rather than true balance.
Board pearl: The flows calibrated can be deceiving in BiVAD insertions, especially when pulmonic or aortic insufficiency allows recirculation.
Q20 / 110
Which scenario is a recognized indication for temporary RVAD support?
Correct answer: B — Massive pulmonary embolism with RV failure
Massive pulmonary embolism with RV failure is a recognized indication for temporary RVAD support, but the scenario deserves the same double-click noted in question 13. ESC guidelines suggest utilization of tRVAD for acute RHF as a grade IIb recommendation, whereas AHA guidelines still suggest VA-ECMO as a primary approach due to complete support during complex embolectomy strategies for clot retrieval. VA-ECMO is associated with greater amounts of bleeding and vascular complications; however, when direct embolectomy and surgical approaches are not planned, Impella RP may be a viable tMCS device.
Board pearl: For massive pulmonary embolism, decide whether the patient needs isolated RV support or full cardiopulmonary support.
Massive pulmonary embolism with RV failure is a recognized indication for temporary RVAD support, but the scenario deserves the same double-click noted in question 13. ESC guidelines suggest utilization of tRVAD for acute RHF as a grade IIb recommendation, whereas AHA guidelines still suggest VA-ECMO as a primary approach due to complete support during complex embolectomy strategies for clot retrieval. VA-ECMO is associated with greater amounts of bleeding and vascular complications; however, when direct embolectomy and surgical approaches are not planned, Impella RP may be a viable tMCS device.
Board pearl: For massive pulmonary embolism, decide whether the patient needs isolated RV support or full cardiopulmonary support.
Source(s): Pandey et al. Hemodynamic improvement with Impella RP in acute massive pulmonary embolism: a narrative review of cardiovascular outcomes and pulmonary catheter pressure assessment. Annals of Medicine and Surgery. 2025 May 26;87(7):4303-4309.