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Alternative methods of resuscitation for patients suffering a cardiac arrest after cardiac surgery

The Ohio State University Medical Center, 410 West Tenth Avenue, Columbus, Ohio 43210-1228, USA

Is internal massage superior to external massage for patients suffering a cardiac arrest after cardiac surgery?

Twomey and colleagues [1] published the results of their ‘best evidence’ search, which addressed whether internal cardiac massage is superior to external massage for patients suffering a cardiac arrest after cardiac surgery. They pointed out that ILCOR recommends prompt conversion to open-chest-cardiac massage in patients shortly post-cardiac surgery. Based on their results, they support this intervention if simple resuscitative efforts such as defibrillation, pacing or atropine fail.

However, two other interventions are worth mentioning. First, minimally invasive direct cardiac massage (or MID-CM) [2] is a technique that uses a hand-held device that is introduced through a small thoracostomy to achieve direct cardiac compression. The commercially available MID-CM device (TheraCardia, Inc) consists of a 40 French external diameter hollow introducer with a round cylindrical handle at one end and a flat umbrella-shaped device at the other end, which is initially collapsed and retracted in the lumen of the introducer. After inserting the introducer through a small incision made at the left anterior fourth intercostal space 5 cm from the midline, the umbrella is deployed, which expands to a diameter of 7.5 cm. Manual cardiac compression-decompressions are performed at 80–100 per min with a 4-cm up-and-down stroke. A human pre-hospital pilot study of 25 patients concluded that MID-CM produces greater blood flow than conventional CPR. Deployment of the MID-CM device was, however, not possible in 1 patient with pericardium adhesions and cardiomegaly. It was pointed out that porcine models comparing open-chest-cardiac massage (OC-CM) to MID-CM using a prototype device concluded that no differences can be found between OC-CM and MID-CM at any point.

Second, abdominal compressions-only CPR (or ACO-CPR) [3] is a new method of resuscitation that recently has been demonstrated to be hemodynamically superior to conventional chest compressions in a porcine model [4]. Blood flow during ACO-CPR is generated by creating an ‘inertial’ pump within the abdominal aorta [5]. Motion of blood within the aorta (due to rhythmic compression by compressing the abdomen) creates an ‘inertial pump’ at particular frequencies of oscillation and the effectiveness of this pump mechanism is highly dependent upon the frequency of oscillations. High-frequency compressions of the aorta are likely most effective at producing resonant pressure-volume waves within the aorta that drive blood flow. This method of CPR also engorges the heart with blood (or primes the pump). ‘Priming the pump’ with ACO-CPR prior to performing chest compressions has been suggested to cause a leftward shift of the flow-depth relationship, thereby allowing viable perfusion pressures to be generated with less depth of compression. Therefore, chest compressions following ACO-CPR are likely much more effective than during conventional CPR. The advantage of ACO-CPR is that it can be applied immediately to generate blood flow to the heart and brain and improve the chances of successfully using initial interventions such as defibrillation, pacing or atropine. However, cardiac compression may still be necessary and perhaps because a bloodengorged heart cannot be successfully defibrillated and circulation cannot return without first decompressing the heart with either OC-CM, MID-CM or conventional CPR.

	References

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1. Twomey D, Das M, Subramanian H, Dunning J. Is internal massage superior to external massage for patients suffering a cardiac arrest after cardiac surgery? Interact Cardiovasc Thorac Surg 2008; 7:151–157.[Abstract/Free Full Text]
2. Rozenberg A, Incagnoli P, Delpech P, Spaulding C, Vivien B, Kern KB, Carli P. Prehospital use of minimally invasive direct cardiac massage (MID-CM): a pilot study. Resuscitation 2001; 50:257–262.[CrossRef][Medline]
3. Rottenberg EM. The need for a leftward shift in the flow-depth relationship during cardiopulmonary resuscitation. Resuscitation 2007; 72:350–352.[CrossRef][Medline]
4. Geddes LA, Rundell A, Lottes A, Kemeny A, Otlewski M. A new cardiopulmonary resuscitation method using only rhythmic abdominal compression. A preliminary report. Am J Emerg Med 2007; 25:786–790.[CrossRef][Medline]
5. Babbs CF. Biophysics of cardiopulmonary resuscitation with periodic z-axis acceleration or abdominal compression at aortic resonant frequencies. Resuscitation 2006; 69:455–469.[CrossRef][Medline]

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