Open-chest cardiac massage without major thoracotomy: metabolic indicators of coronary and cerebral perfusion

doi:10.1016/S0300-9572(97)01116-7

Resuscitation

Volume 34, Issue 3, June 1997, Pages 247-253

https://doi.org/10.1016/S0300-9572(97)01116-7 Get rights and content

Abstract

Objective: to compare the coronary and cerebral perfusion achieved using a novel method of minimally-invasive, direct cardiac massage to that obtained using bimanual, open-chest cardiac massage. Design: prospective, controlled animal study with repeated measures. Setting: university research laboratory. Subjects: large domestic swine. Interventions: aortic, coronary sinus, jugular venous and pulmonary artery catheters were placed. Following an equilibration period, ventricular fibrillation was induced. After 4 min of untreated ventricular fibrillation, animals underwent bimanual, open-chest cardiac massage (N=6) or minimally-invasive, direct cardiac massage using a novel device for direct cardiac compression (N=6). Adrenaline was administered at a dose of 1 mg intravenously every 5 min. Measurements: systemic metabolic parameters, (arterial P_O₂, P_CO₂ and lactate concentration) and coronary sinus and jugular venous metabolic parameters (pH, PV_O₂, SV_O₂, PV_CO₂ and lactate concentration) were measured and calculated (coronary sinus/jugular-arterial SV_O₂, coronary sinus/jugular-arterial P_CO₂ and lactate differences) at baseline and at 10, 20 and 30 min following induction of ventricular fibrillation. Animals were euthanised after 30 min with no attempt at defibrillation. Main Results: oxygen tension and oxygen saturation of coronary sinus blood declined significantly during the experimental period, but no differences were noted between treatment groups. The coronary sinus-arterial oxygen saturation difference increased during the study with no significant differences between groups. Coronary sinus P_CO₂ and the coronary sinus-arterial P_CO₂ difference increased significantly in both experimental groups during cardiac massage. No inter-group differences were noted. A similar relationship was noted in coronary sinus lactate values. The coronary sinus-arterial lactate difference displayed a positive balance at all intervals with no differences noted between group values. The oxygen tension and oxygen saturation of jugular venous blood, were reduced from baseline levels with both treatments. The jugular-arterial oxygen saturation difference increased in both groups compared to baseline values. Between group values were significantly different only at the 20 min interval. Both the jugular venous P_CO₂ and the jugular-arterial P_CO₂ gradient were elevated at all intervals, but no inter-group differences were noted. Jugular venous lactate concentration rose steadily with time in both groups. No significant increase in the jugular-arterial lactate gradient was noted at any time point. Conclusions: minimally-invasive, direct cardiac massage provides coronary and cerebral perfusion similar to that achieved using standard open-chest cardiac massage. This method may provide a more effective substitute for standard, closed-chest cardiac massage in cases of refractory cardiac arrest.

Introduction

Sudden cardiac arrest is the leading cause of unexpected death in the USA [1]. Only a small minority of treated victims achieve long-term, neurologically-intact survival 2, 3, 4, 5, 6, 7. Even in the most optimal of circumstances, when cardiac arrest occurs in the hospital and Basic and Advanced Cardiac Life Support are rapidly employed, less than 50% of patients have a restoration of spontaneous circulation and fewer than 25% are discharged alive 3, 8, 9, 10, 11, 12. The poor results with current therapies for cardiac arrest have driven the quest for interventions which can increase the likelihood of neurologically-intact survival.

The low coronary and cerebral perfusions generated during closed-chest resuscitation may be limiting factors in the probability of survival following cardiac arrest 5, 13, 14. Measures which increase coronary and cerebral perfusion during the period of cardiac arrest may improve the probability of successful resuscitation. Among such measures, open-chest cardiac massage has been shown to produce higher systemic blood pressure and flow, and improved perfusion of the brain and heart compared to standard, closed-chest compression 15, 16, 17, 18, 19, 20. Open-chest cardiac massage may increase the probability of restoring spontaneous circulation and survival 21, 22, 23, 24. We have previously described the technique of minimally-invasive, direct cardiac massage, performed using a plunger-like device via a small, intercostal incision [25]. This method obviates the need for a major thoracotomy. The present work reports the metabolic indicators of global coronary and cerebral perfusion obtained during minimally-invasive, direct cardiac massage compared to those produced by conventional open-chest cardiac massage.

Section snippets

Materials and methods

The protocol for this study was approved by The Animal Care and Use Committee of Temple University. All work was performed in accordance with the `Guide for the Care and Use of Laboratory Animals' prepared by the National Research Council of the NIH.

Results

Metabolic indicators of coronary perfusion are displayed in Table 1Table 2. The oxygen tension and oxygen saturation of coronary venous blood declined markedly in both groups by 10 min following induction of ventricular fibrillation. A modest further decline in both parameters occurred thereafter. No significant differences in values between massage techniques were observed at any interval. The coronary sinus-arterial oxygen saturation difference increased significantly in both groups during

Discussion

This study was designed to test the hypothesis that cardiac massage, performed via a small, intercostal incision with a novel plunger device, could sustain coronary and cerebral perfusion as effectively as conventional, open-chest cardiac massage. The small sample size precludes the statement that the two methods are identical with regard to supporting organ perfusion, however, any differences in efficacy appear to be small. Whether such differences are of clinical importance are not known.

The

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Part 4: Advanced life support
2005, Resuscitation
Are US informed consent requirements driving resuscitation research overseas?
2005, Resuscitation
Following a 2-year federally imposed moratorium on acute resuscitation research due to concern regarding the inability of patients in cardiac arrest to provide prospective, informed consent to participate in such research, the United States federal government in 1996 released regulations with provisions for exemption of prospective informed consent in certain types of emergency research. While very few acute resuscitation research studies have been attempted in the United States since that time, such research has continued overseas. We discuss one large multi-center, out-of-hospital trial of a device intended to improve the hemodynamics of cardiopulmonary resuscitation. After pilot implementation overseas, this trial could not be conducted in the United States, largely due to the difficulties and costs involved in implementing the requirements of the 1996 regulations. A recent European Union directive on the conduct of clinical trials may halt European research on patients who are unable to provide prospective, informed consent. The directive contains no provisions for exceptions or waiver of informed consent, and may hinder acute resuscitation research in Europe to an even greater degree than the 1996 regulations have in the United States.
Open-chest cardiopulmonary resuscitation: Past, present and future
2005, Resuscitation
Out-of-hospital cardiac arrests account for approximately 1000 sudden cardiac deaths per day in the United States. Since its introduction in 1960 closed-chest cardiac massage (CCCM) often takes place as an attempt at resuscitation, although its survival rates are low. Other resuscitation techniques are available to physicians such as open-chest cardiopulmonary resuscitation (OCCPR).
OCCPR has been shown by several scientists to be hemodynamically superior to CCCM as it increases arterial pressures, cardiac output, coronary perfusion pressures, return of spontaneous circulation and cerebral blood flow. Improved neurological and cardiovascular outcome and an increase in survival rate compared to CCCM have been described. Timing is one of the key variables in determining patient outcome when performing OCCPR. The American Heart Association in association with the International Liaison Committee (ILCOR) has specific indications for the use of OCCPR. Some investigators recommend starting OCCPR in out-of-hospital cardiac arrests on arrival at the scene instead of CCCM. Surprisingly, the incidence of infectious complications after thoracotomy in an unprepared chest is low. The vast majority of the patients’ families accept OCCPR as a therapeutic choice for cardiac arrests and it has been showed to be economically viable. This paper reviews some of the basic and advanced concepts of this evolving technique.
Insertion of the minimally invasive direct cardiac massage device (MIDCM): Training on human cadavers
2002, Resuscitation
Objective: Recently, a new device for minimally invasive direct cardiac massage (MIDCM) has been developed. In animal models of cardiopulmonary resuscitation MIDCM has been shown to provide better organ perfusion than external chest compressions (ECC) massage. Since this device has been developed to improve cardiopulmonary resuscitation in humans, its use must be simple. Thus, we measured the time required for the insertion of the MIDCM device on human cadavers. Design: After a 1 h theoretical course, physicians and surgeons were asked to use the MIDCM device on human cadavers. We measured the time from the cutaneous incision to the first direct cardiac compression. Main results: The mean time required for the insertion of the MIDCM device was 16±11 s (range 8–58 s). The insertion time required for each group of physicians were as follows, 15±8 s for anaesthesiologists (range 8–28 s), 11±2 s for cardiac surgeons (range 9–15 s), 42±14 s for cardiologists (range 27–58 s), and 12±4 s for intensive care physicians (range 8–18). All participants compared the insertion of the MIDCM device favorably with the insertion of a chest drain. Conclusion: The MIDCM device can be placed in a few seconds in human cadavers by physicians familiar with chest drain insertion. Theoretical course and training with the device may be useful especially for those who are not familiar with chest drain insertion.
New aspects and perspective on cardiopulmonary resuscitation
2002, Annales Francaises d'Anesthesie et de Reanimation
Objectif : Faire le point sur les avancées actuelles de la recherche expérimentale et clinique dans les principaux domaines de la réanimation cardiopulmonaire.
Source des données : Recommandations internationales et revues générales récentes. Recueil des données à partir de la base de données Medline® à partir du mot-clé : cardiac arrest.
Sélection des travaux : Les travaux expérimentaux et cliniques des dix dernières années ont été analysés et les informations cliniques pertinentes ont été extraites. Les nouveautés dans les recommandations qui en découlent sont discutées.
Synthèse des données : Des évolutions prometteuses sont proposées pour la réanimation cardiopulmonaire de base et pour la réanimation médicalisée. Le massage cardiaque doit être privilégié par rapport à la ventilation ; son rythme doit être augmenté à 100 compressions/min. Des techniques alternatives au massage cardiaque classique sont envisagées. Les volumes de ventilation doivent être réduits de 1000 mL à environ 500 mL par insufflation en oxygène pur. Les défibrillateurs à ondes biphasiques et les défibrillateurs semi-automatiques sont les appareils de lˈavenir. Des vasopresseurs non catécholaminergiques pourraient limiter la place de lˈadrénaline dans la réanimation médicalisée. La lidocaïne est concurrencée par lˈamiodarone comme anti-arythmique de choix. De nouvelles stratégies thérapeutiques post-arrêt cardiaque sont évaluées, en particulier la reperfusion coronaire en cas dˈorigine cardiaque de lˈarrêt.
Conclusion : De nombreux domaines de la réanimation cardiopulmonaire sont en cours dˈévolution. Les dernières recommandations internationales publiées en 2000 prennent en compte un certain nombre de ces avancées, mais la majorité dˈentre elles devra être confirmée par des études complémentaires avant de pouvoir être proposée en routine.
Objectives: To analyse the current knowledge based on the experimental and the clinical research studies focused on the main fields of cardiopulmonary resuscitation.
Data sources: International guidelines and recent review articles. Data collected from the Medline database with the key word: cardiac arrest.
Study selection: Research studies published during the last ten years were reviewed. Relevant clinical information was extracted and discussed when it induced changes in guidelines.
Data synthesis: Promising improvements on basic and advanced life supports are proposed. Chest compressions prevail over ventilation. Alternatives to classical chest compressions are tested. Ventilatory volume must be reduced from 1000 to approximatively 500 mL for each breath with oxygen. Biphasic waveform defibrillators and automated external defibrillators will be considered as the best devices in the near future. Some non-catecholaminergic vasopressors could reduce the use of epinephrine for advanced cardiac life support. Lidocaine could be replaced by amiodarone as anti-arrhythmic drug of choice. New post-resuscitation therapeutic strategies are evaluated, especially coronary reperfusion when the cause of cardiac arrest is cardiac.
Conclusion: Many fields of cardiopulmonary resuscitation are investigated. Some relevant informations are included in the last international guidelines published in 2000, but most of them need complementary studies before other changes could be recommended for routine practice.
Prehospital use of minimally invasive direct cardiac massage (MID-CM): A pilot study
2001, Resuscitation
Background: Internal cardiac compressions are more efficient than closed chest compressions (CCC) in cardiac arrest (CA). Aim of the study: To evaluate the prehospital feasibility of performing a new method of minimally invasive direct cardiac massage (MID-CM^® TheraCardia Inc.). Methods: Prospective non-randomized open study, after ethical committee approval. Inclusion of 18–85 years old patients in witnessed CA if BLS>5 min and unsuccessful ACLS>20 min after CA. The MID-CM is an atraumatic manual cardiac pumping system deployed in the thoracic cavity through a small incision. Evaluation of: ease of insertion and performing MID-CM, complications, end-tidal CO₂ (PETCO₂), non invasive arterial blood pressure (NIBP) and return of spontaneous circulation (ROSC). Values are mean±SD (min–max). Results: Twenty-five patients included. Mean age 59±16 years (26–85); BLS started at 8±5 min (0–20), compressions started at 47±10 min (29–74) after CA. Dissection and insertion was fast and easy (<1 min). Deployment of the MID-CM was difficult in two patients because of pericardium adhesions and cardiomegaly. In six patients compressions were more difficult because of a ‘stone heart’ phenomenon. Compressions were possible during ambulance transport of four patients. There was a good palpable carotid pulse in all patients receiving internal compressions. There was a trend in increase of PETCO₂ compared to CCC. NIBP could be measured during MID-CM compressions in 9 patients (systolic>85 mmHg), never during CCC. Seven patients had a ROSC, but only four patients were admitted alive. There was no long term survival. One patient had a serious complication (heart rupture). Discussion: Prehospital use of MID-CM is possible, but it is not comparable to any other resuscitation technique. Training of medical teams is mandatory to obtain good skills and to avoid complications. Further studies are necessary to evaluate efficiency and survival compared to closed chest compressions.
Pressuposto: A massagem cardı́aca interna é mais eficaz do que a compressão torácica externa em contexto de paragem cardı́aca (PC). Objectivo do estudo: Avaliar a exequibilidade de um novo método de massagem cardı́aca directa minimamente invasiva (MID-CM® TheraCardia Inc.). Métodos: Ensaio prospectivo aberto não randomizado, após aprovação pelo comité de ética. Inclusão de doentes com idades entre os 18 e 85 anos, vı́timas de paragem cardı́aca presenciada se o SBV durante mais de 5 minutos e o SAV durante mais de 20 minutos após paragem cardı́aca fossem ineficazes. O MID-CM é um sistema manual e atraumático para massagem cardı́aca que se introduz dentro do tórax por uma pequena incisão. Foi avaliada a facilidade de introdução e desempenho com o MID-CM, as complicações, o CO₂ tele-expiratório, a pressão arterial não invasiva e o retorno da circulação espontânea. Os valores apresentados são as médias±SD (min–max). Resultados: foram incluı́dos vinte e cinco doentes. A idade média era de 59±16 anos (26–85); o SBV foi iniciados aos 8±5 minutos (0–20), a compressão iniciou-se aos 47±10 min (29–74) após PC. A dissecção e inserção foi fácil e rápida (< 1 min). A colocação do MID-CM foi difı́cil em dois casos por cardiomegalia e aderências pericárdicas. Em seis dos doentes as compressões foram mais difı́ceis pela ocorrência do fenómeno do “coração em pedra”. As compressões poderam ser feitas durante o transporte de ambulância em quatro doentes. O pulso carotı́deo era bom e palpável em todos os doentes em massagem cardı́aca interna. Verificou-se um tendência para que o CO₂ tele-expiratório fosse mais elevado do que nos doentes que fizeram compressões torácicas externas. Em nove dos doentes com MID-CM foi possı́vel medir a pressão arterial não invasiva (sistólica>85mmHg), o que nunca aconteceu nos doentes em compressões torácicas externas. Sete doentes recuperaram circulação espontânea mas só quatro foram hospitalizados vivos. Não houve sobrevida a longo prazo. Um dos doentes teve sérias complicações cardı́acas (rotura do miocárdio). Discussão: a utilização do MID-CM em ambiente pré hospitalar é possı́vel, mas não é comparável a nenhumas das outra técnicas de reanimação. Para obter bons resultados e minorar as complicações é mandatório o treino das equipas médicas. São necessário mais estudos para avaliar a eficácia e a sobrevida em comparação com a compressão torácica externa.

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¹: Conflict of interest: Drs Buckman and Badellino are co-inventors of the device used to perform minimally-invasive, direct cardiac massage and have financial interests in the company developing the device.

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