Percutaneous repositioning of Impella RP: the Snare–Manoeuvre–Prolapse technique—a case report

BACKGROUND: Impella RP (Abiomed, Danvers, MA, USA) is indicated for right ventricular failure after left ventricular assist device insertion or biventricular shock. Once the peel-away sheath is removed, Impella RP repositioning can only be achieved with manual manipulation of the catheter itself. This method does not always accomplish appropriate positioning of the catheter and can result in continued haemodynamic instability. CASE SUMMARY: A young male presented to our institution with recurrent ventricular fibrillation and ST-elevation myocardial infarction that underwent emergent coronary intervention but was in progressive cardiogenic shock requiring implantation of Impella 5.0 and Impella RP. After insertion of the right ventricular support, the patient stabilized transiently then became unstable once more, and repeat fluoroscopy demonstrated that the Impella RP had ‘fallen back’ into the right ventricle. Due to continued instability, we improvised a previously undescribed method of repositioning of the Impella RP catheter with the use of a goose-neck snare. DISCUSSION: The snare–manoeuvre–prolapse method of Impella RP repositioning is a relatively novel approach at the management of Impella RP retrograde migration into the right ventricle and prevents the need for large-bore venous closure and re-access and the use of a new Impella RP catheter while providing rapid improvement of haemodynamics.