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Interact CardioVasc Thorac Surg 2008;7:151-157. doi:10.1510/icvts.2007.170399 © 2008 European Association of Cardio-Thoracic Surgery
Is internal massage superior to external massage for patients suffering a cardiac arrest after cardiac surgery?
a Department of Cardiology, James Cook University Hospital, Middlesbrough, UK Received 16 October 2007; accepted 23 October 2007
*Corresponding author. Tel./fax: +44 1642 850850.
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether open chest cardiac massage is superior to closed chest compressions in patients suffering cardiac arrest following cardiac surgery. Using the reported search, 527 papers were identified. Fifteen papers represented the best evidence on the subject and the author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study comments and weaknesses were tabulated. The quality and level of evidence was assessed using the International Liaison Committee on Resuscitation guideline recommendations. We conclude that over 18 good quality animal studies have consistently demonstrated the superiority of open chest cardiac massage, with the cardiac index and coronary perfusion pressures often more than doubling. There are fewer human studies but they have shown that closed chest massage generates a cardiac index of around 0.6 l/min/m2 which rises to 1.3 l/min/m2 or more with open-chest-CPR, accompanied by even bigger improvements in coronary perfusion pressure. ILCOR recommends prompt conversion to open-chest-cardiac massage in patient's shortly post-cardiac surgery, and we would support this intervention if simple resuscitative efforts such as defibrillation, pacing or atropine fail, in order to significantly improve the quality of cardiopulmonary resuscitation.
Key Words: Cardiac surgery; Cardiopulmonary resuscitation; Open chest cardiac massage; Evidence based medicine; Postoperative complications
A best evidence topic was written according to a structured protocol. This protocol is fully described in the ICTVS [1]. The quality of each study was assessed using the International Liaison Committee on Resuscitation 2005 protocol [2].
A 52-year-old patient 36 h after mitral valve repair and grafts arrests with an asystolic ECG. He had been on increasing doses of adrenaline and a TOE had shown a poor LV but no tamponade. After 2 min of external cardiac massage and 1 mg of adrenaline you elect to perform an emergency re-sternotomy with the intention of putting the patient back on bypass. Once commencing internal massage you are surprised at the significantly better arterial pressure that you are able to achieve performing internal massage.
In [patients with cardiac arrest after cardiac surgery] is [external cardiac massage or internal massage] better in generating optimal [cardiac index and coronary perfusion]?
Medline 1950–Oct 2007 using the OVID interface. [open chest.mp OR internal cardiac.mp OR resuscitative thoracotomy.mp OR open heart.mp] AND [CPR.mp OR exp Cardiopulmonary resuscitation/or massage.mp] EMBASE 1980–Oct 2007 using the OVID interface. [open chest.mp OR internal cardiac.mp OR resuscitative thoracotomy.mp OR open heart.mp] AND [CPR.mp OR exp resuscitation/or massage.mp] The Cochrane database for systematic reviews and central register of controlled trials was searched using the term ‘open chest’, or ‘internal cardiac’ CPR.
Two hundred and sixty-three papers were found in Medline, 256 in EMBASE and eight articles in the Cochrane library. Of these, 22 were felt to be relevant and 15 were tabulated (Table 1).
The International Liaison Committee on Resuscitation which comprehensively reviewed 276 topics in resuscitation with 281 experts in the field in 2005 looked at the issue of open vs. closed chest cardiac massage [3], and provided a systematic review on the topic as part of their worksheet review process [4]. They found four human studies, with two in cardiac surgery and two in out-of-hospital cardiac arrest and 18 animal studies. They report that there are observed benefits of open-chest-cardiac massage including improved coronary perfusion pressure and increased return of spontaneous circulation in humans and better survival rates, and organ blood flow as compared to closed-chest CPR. They recommend that open-chest-CPR should be considered for patients for cardiac arrest in the early postoperative phase after cardiothoracic surgery or when the chest or abdomen is already open (Class IIb). The two human studies after cardiac surgery referred to were by Anthi et al. [5] and Pottle et al. [6]. Anthi provided a report of 29 patients who arrested 24 h after cardiac surgery. Forty-five percent were resuscitated with closed-chest-CPR and 48% with open-chest-CPR after 2–5 min of closed-chest massage had failed. Pottle reported 72 patients who had open-chest-CPR after cardiac surgery, of whom 46% regained spontaneous circulation. Of the other two human studies, Boczar et al. [7] studied 10 patients brought into hospital with a witnessed cardiac arrest. After 5 min of closed-chest-CPR they were declared unsalvageable and entered into the study. A left lateral thoracotomy was performed without opening the pericardium and internal massage commenced. The mean coronary perfusion pressure rose from 7.3 mmHg to 32 mmHg, the compression-phase pressure gradient rose from 6.2 mmHg to 32.6 mmHg and three patients obtained a spontaneous circulation. They remind us that Paradis et al. [8] in JAMA reported that 15 mmHg of coronary perfusion is required in humans to obtain a return of spontaneous circulation, this was achieved in all Boczar's patients during open-chest-CPR. Paradis et al. [9] also reported three patients who had open-chest-CPR after failed closed-chest-CPR and two survived, one with no neurological deficit. Takino and Okada [10] compared 26 patients who had open-chest-CPR after witnessed out-of-hospital cardiac arrest with 69 who had closed-chest-CPR only. Fifty-eight percent of patients had spontaneous return of circulation with open-chest-CPR compared with 30% with closed-chest-CPR. There were three open-chest long-term survivors compared to only one closed-chest survivor. A third human study rejected by ILCOR was by Hachimi-Idrissi et al. [11]. They found 33 patients who had open-chest-CPR after failed closed-chest-CPR in their database of 2212 out-of-hospital arrest patients. Thirteen had spontaneous return of circulation but only two survived. We identified three additional human studies. Del Guercio et al. in 1965 [12] showed significant improvements in physiological variables with open-chest-CPR in 11 patients with in-hospital arrest. The cardiac index was 0.6 l/min/m2 with closed-chest-CPR but was 1.3 l/min/m2 with open-chest-CPR. The circulation time decreased from 89 s to 44 s. Calinas-Correia and Phair [13] reported seven patients who underwent open-chest CPR but with no survivors. Geehr et al. [14] in a letter in the NEJM, reported that they had performed an RCT of 49 patients with an out-of-hospital arrest and found three survivors in the open-chest-CPR group, and three in the closed-chest-CPR group. Of the animal studies, Benson et al. [15] induced VF in 12 dogs and after 5 min of no intervention randomised the dogs to either open or closed-chest-massage for 15 min. All open-chest-CPR dogs survived without neurological deficit but only 3/7 dogs survived after closed-chest-CPR and two had severe neurological deficit. The coronary perfusion pressure was double in the open-chest-CPR group. Sanders et al. [16] showed that open-chest-CPR resulted in 4/5 dog survivors compared to none in their closed-chest group. Kern et al. [17] showed that resuscitation and survival were significantly improved with open cardiac massage in 29 dogs and reiterated these findings in 1991, adding that resuscitation was significantly improved if chest opening was instituted sooner. Raessler and Kem [18] in 63 mongrel dogs showed that open-chest-CPR had a coronary perfusion pressure of 64 mmHg compared to 21 mmHg for closed-chest massage. Rubertsson and Grenvik [19] showed significant improvements in cardiac index and coronary perfusion pressure in 35 pigs.
Over 18 good quality animal studies have consistently demonstrated the superiority of open chest cardiac massage, with the cardiac index and coronary perfusion pressures often more than doubling. There are fewer human studies but they have shown that closed-chest-massage generates a cardiac index of around 0.6, which rises to 1.3 l/min/m2 or more with open-chest-CPR, accompanied by even bigger improvements in coronary perfusion pressure. ILCOR recommends prompt conversion to open-chest-cardiac massage in patients shortly post-cardiac surgery, and we would support this intervention if simple resuscitative efforts such as defibrillation, pacing or atropine fail, in order to significantly improve the quality of cardiopulmonary resuscitation.
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Abstract
1. Introduction
