Echocardiographic Assessment Before, During, and After Impella Positioning: State of the Art

Echocardiographic assessment is essential for evaluating patients with cardiogenic shock (CS) and determining their potential need for mechanical circulatory support (MCS) implantation. The use of Impella devices has increased significantly in recent years, paralleling the growing recognition of their hemodynamic benefits in selected patient populations. As the clinical experience with these devices has expanded, the need for a more standardized imaging approach has emerged. Both transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) play complementary roles in guiding the pre-implantation evaluation, placement procedure, and post-implantation management of Impella devices. Currently, no comprehensive guidelines exist concerning the echocardiographic evaluation of Impella devices throughout their entire clinical course, from initial patient selection and device implantation to ongoing monitoring and eventual weaning. This gap in standardized guidance has led to significant variability in clinical practice across different institutions and healthcare systems. This comprehensive review examines the role of transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) in managing patients on Impella support across five distinct phases: candidate identification and pre-implantation assessment, intraoperative procedural guidance and device positioning, postoperative monitoring and haemodynamic optimisation, complication detection and troubleshooting, and weaning strategies with post-explantation surveillance. Both left-sided devices (Impella CP, CP Smart Assist, and Impella 5.5) and right-sided support (Impella RP) are covered, including combined configurations with VA-ECMO (ECPella). For each phase, we detail the recommended echocardiographic views, essential measurements and their evidence-based thresholds, signs of device malposition, and practical corrective strategies. A level-of-evidence approach is adopted throughout, specifying whether proposed thresholds derive from randomised trials, observational studies, expert consensus, or manufacturer recommendations. Summary tables and a bedside workflow are provided to facilitate immediate clinical application.