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eComment: The sooner the beginning of cardiopulmonary resuscitation, the better the outcome for the arrested cardiac operated patient

Cardiothoracic Surgery Department, University Hospital of Patras, 22500 Rion Patras, Greece

If a patient arrests after cardiac surgery is it acceptable to delay cardiopulmonary resuscitation until you have attempted either defibrillation or pacing?

The two questions posed by your article [1] are of great importance as they concern every surgeon.

Concerning the first question, the immediate cardiopulmonary resuscitation (CPR) is not only necessary but also mandatory. We strongly believe that CPR should start as soon as possible, independently of the availability for defibrillation or pacing. We consider maintaining of an adequate blood flow and pressure for vital organs (brain and myocardium), before every effort to defibrillate or pacing, as the most important constituent of a good final outcome. Cerebral blood flow must be preserved within first 2–3 min following arrest, in order to avoid a potential irreversible damage.

Immediate CPR is also imposed in cases where arrest is associated with acute dilation of left or right ventricle (ballooning heart). In these cases (on electrocardiogram: bradycardia, asystole, or pulseless electrical activity), attempting to pace or defibrillate is usually not effective. Acute ‘passive’ myocardial dilatation leads to a further deterioration of the ventricular function because the curve of Frank-Starling is shifted to the right. Simultaneously, the myocardium presents an asynergy, regarding ventricular conduction contrary to the normal excitation–contraction coupling. Consequently, if we do not interrupt mechanically this ‘vicious circle’ by cardiac massage, neither pacing nor defibrillation will be rendered effective.

Concerning the possibility of myocardial damage caused by external cardiac massage [1], there are few sporadic reported cases in literature [2, 3]. However, such cases are relatively rare compared to the total amount of patients subjected in CPR. It is notable that Fredriksson et al. [4] do not refer to any myocardial damage during post-cardiopulmonary bypass grafting (CABG) arrest, among 32 postoperative patients, in the majority of whom (80%) a cardiac massage was performed. El-Banayosy et al. [2] reported no cases of myocardial injury during CPR among 113 cardiac operated patients. However, there are several reported cases of harm after CPR in patients without previous sternotomy. Consequently, previous sternotomy does not appear to be significantly responsible for a potential myocardial injury or dysfunction during CPR.

In our opinion, myocardial damage may be caused by physician’s over zealous massage, usually characterized by violent manoeuvres. According to the guidelines, during external massage the ‘immersion’ of the lower half sternum must not exceed 4–5 cm, in order to produce drastic mechanical output without the potential of myocardial damage [5].

Finally, we follow a more ‘aggressive strategy’ for the arrested patients shortly after cardiac surgery: we immediately perform CPR by external cardiac massage. If after the first 2–3 min ‘closed CPR’ has no impact, we convert it to ‘open CPR’ after in bed emergency re-sternotomy. This strategy has been performed in 26 arrests on ICU patients and was successful in 18 patients (69.23%). In only one case we have observed at the end of a converted ‘open CPR’ a hemorrhage from the site of left internal mammary artery (LIMA) to left anterior descending (LAD) anastomosis. The patient was urgently transported to the theater for successful suture. Two others of the surviving patients were re-operated after two and three months, respectively for complications of the incision and of the sternum (infection and diastasis).

	References

Top References

 

1. Lockowandt U, Levine A, Strang T, Dunning J. If a patient arrests after cardiac surgery is it acceptable to delay cardiopulmonary resuscitation until you have attempted either defibrillation or pacing? Interact CardioVasc Thorac Surg 2008;7:878–887.[Abstract/Free Full Text]
2. El-Banayosy A, Brehm C, Kizner L, Hartmann D, Koertke H, Koerner M, Minami K, Reichelt W, Koerfer R. Cardiopulmonary resuscitation after cardiac surgery: a two-year study. J Cardiothorac Vasc Anesth 1998;12:390–392.[CrossRef][Medline]
3. Boehrer G, Boettiger B. Cardiopulmonary resuscitation after cardiac surgery. J Cardiothorac Vasc Anesth 1995;9:352.[CrossRef][Medline]
4. Fredriksson M, Aune S, Thoren AB, Herlitz J. In-hospital cardiac arrest – an Utstein style report of seven years experience from the Sahlgrenska University Hospital. Resuscitation 2006;68:351–358.[CrossRef][Medline]
5. Myerburg R, Castellanos A. Cardiac arrest and sudden cardiac death. In: Zipes D, Libby P, Bonow R, Braunwald E, editors, Braunwalds heart disease, 7th Ed, Elsevier Saunders; 2005:93.

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