Open Heart Massage


Article Author:
Ryan D'Souza


Article Editor:
Luke Law


Editors In Chief:
Yvonne Carter
Jason Wallen


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes


Updated:
12/26/2018 3:45:01 PM

Introduction

Before the implementation of closed chest compressions in the early 1960s, open cardiac massage was a common procedure performed during cardiac arrest. Open cardiac massage is typically performed on patients with inadequate cardiac output status, post-emergency thoracotomy for penetrating chest trauma, pericardial tamponade, or cardiac arrest after recent chest surgery.[1][2] The development of this technique is attributed to Mortiz Schiff, a physiologist in the 19th century, who described open cardiac massage after heart function cessation in laboratory animals.[3] Following this description, the first attempt of open cardiac massage was performed by Niehans in 1880.[4] It was not until 1901 that Kristian Ingelsrud achieved the first successful outcome from open cardiac massage in cardiac arrest. The use of open cardiac massage became common after the 1920s, and the preferred method for cardiovascular collapse in the first half of the 20th century, after the report of 99 cases by Lee and Downs with a reported overall survival of 25%.[5]

Anatomy

When a surgeon performs an open thoracotomy to access the heart, knowledge of cardiothoracic anatomy is crucial. During dissection, the lungs must be held out of the way bilaterally. After sawing or clipping through the sternum and accessing the heart encased in the pericardium, the surgeon may incise through the pericardium to allow full access to the heart in the case of cardiac tamponade.[6] They must take care to avoid the phrenic and intercostal nerves[1][6] and vascular injury to the intercostal, pulmonary, and internal mammary vessels.

Indications

The American Heart Association and the International Liaison Committee on Resuscitation recommend open cardiac massage under certain circumstances such as penetrating cardiac arrest.[7] Authors report other indications for cardiac arrest after recent cardiac surgery and decompression of pericardial tamponade.[1][8][9] Some recommend open cardiac massage when standard advanced life support protocols do not restore spontaneous circulation within 5 to 10 minutes.[10] Other potential indications include abnormal chest wall anatomy preventing effective, closed-chest compressions, refractory ventricular fibrillation, and massive air embolism.

Contraindications

The only organic contraindication is the presence of a pulse.[6] Known patient wishes which preclude resuscitation, for example, a "do not resuscitate" order, are another contraindication.

Equipment

The necessary equipment needed to perform an emergency thoracotomy includes the following:

  • Chlorhexidine gluconate or povidone iodine
  • Gigli saw
  • Large clamp or forceps
  • Large scalpel
  • Large scissors

Personnel

A cardiothoracic surgeon with experience in performing a rapid median sternotomy under 2 minutes is preferable. However, a non-specialist surgeon may also be able to perform an emergency, open thoracotomy in 2 to 3 minutes.[6] Additional staff members, including the scrub nurse, may assist.

Preparation

Typically, the need for open cardiac massage manifests during emergencies, and thus, health care professionals are exempted from informed consent in these situations. However, these health care professionals must pay careful attention and document the patient’s code status.

The patient is positioned in the supine position. The anesthesiologist or other intensive care providers should secure the airway and obtain adequate vascular access for fluid and pharmacologic administration. Due to the urgency, a complete aseptic technique is often omitted, or a rapid application of skin preparation (chlorhexidine gluconate or povidone-iodine) may suffice.

Technique

Bilateral Anterior Thoracotomy Approach 

The surgeon uses a scalpel to make bilateral thoracostomies in the 5 intercostal space at the mid-axillary line. She or he then connect the thoracostomies with a deeper skin incision. Layers of the intercostal muscles and pleura are dissected as the surgeon advances towards the sternum. The surgeon then cuts through the sternum using heavy scissors or a Gigli saw. Once they excise the sternum, they make an incision in the pericardium only if pericardial tamponade is suspected; otherwise, an intact pericardium is preferable to prevent inadvertent damage to the atria and ventricles if the heart is compressed inappropriately. The surgeon evacuates blood and performs any clots, if necessary, then accesses the heart.

Wise and colleagues[6] recommend a 2-handed technique for internal cardiac massage: a flat hand is placed under the posterior heart surface, and the other hand is placed on the anterior heart surface. The heart is squeezed from the apex upward at a rate of approximately 100 beats per minute. Caution must be taken to not use fingertips to compress the heart due to increased risk of myocardial injury.

A single-hand technique can also be utilized if the provider’s hand is large enough; in this approach, the provider positions straight fingers at the posterior surface of the heart near the apex and applies the thumb to the anterior surface. It is paramount that the heart remains horizontal throughout internal cardiac massage as lifting the apex may prevent venous filling. Another assistant may compress the descending aorta to maximize blood flow to the coronaries arteries and cerebral vasculature.[6]

Compression rate should adhere to the Advanced Cardiac Life Support guidelines with a rate of at least 100 beats per minute. If the return of spontaneous circulation is accomplished, sterile, saline-dampened gauze is applied to the incision and antibiotics covering skin flora are administered. Definitive prompt surgical closure of thoracotomy, preferably by a cardiothoracic surgeon, is recommended.

Complications

The invasive nature of performing a resuscitative thoracotomy may damage surrounding nerves, blood vessels, lungs, and the heart. Specific nearby nerves include the phrenic and intercostal nerves.[1][6] Vascular injury to the intercostal, pulmonary, and internal mammary vessels may also occur.[1] Damage to the heart in the pericardium, myocardium, or coronary vessels is likely due to direct manipulation of the heart. Patients who achieve successful resuscitation but require thrombolysis due to massive pulmonary embolism or stroke may be challenging because the thoracotomy incision is a relative contraindication to thrombolysis. In these cases, alternative interventions including embolectomy and localized thrombolysis should be considered.[1] Finally, if the patient survives, infection risk of the thoracotomy wound exists, particularly since many emergency thoracotomies are not performed with complete aseptic technique.

Clinical Significance

Before the advent of closed chest compressions, surgeons routinely performed open cardiac massage. Some studies have suggested that open cardiac massage may be a more efficient method of maintaining circulation during cardiac arrest compared to closed cardiac compressions. Recent data on open chest cardiopulmonary resuscitation are lacking. A study published in 1953 demonstrated a recovery rate of 28%.[11] Another study spanning 30 years demonstrated that if open cardiopulmonary resuscitation was performed within 4 minutes of cardiac arrest, recovery rates approached 58% and these patients were neurologically intact.[12] A simple PubMed search strategy to identify trials involving comparisons between open cardiac massage and closed chest compressions only identified 1 prospective observational study within the last 5 years. In a population of patients with traumatic cardiac arrest, a prospective observational study in 2016 reported no significant improvement in end-tidal carbon dioxide or return of spontaneous circulation in a patient receiving open chest cardiac massage following closed chest compressions compared to patients having closed chest compressions only.[2]

Another recent study was identified which described an alternative approach to performing open cardiac massage via a transdiaphragmatic approach.[13] This case series described 6 patients who experienced cardiac arrest during laparotomy (4 liver transplantation cases, 2 trauma cases), and subsequently, open cardiac massage was performed with accessing the heart through a diaphragmatic incision. Only 3 patients regained spontaneous circulation, 2 survived during transit to the intensive care unit, and 1 survived to discharge.

Enhancing Healthcare Team Outcomes

A recent review paper by Kornhall and colleagues reviewed the available evidence on open very closed chest compressions and proposed prior evidence that may support improved physiology and outcomes from open cardiac massage.[1] Physiologically, health care professionals know that the higher the coronary perfusion pressure, the more likely the cardiac arrest patient may achieve a return of spontaneous circulation. An animal study in Mongrel dogs performed in 2003 demonstrated a coronary perfusion pressure of 38.2 mm Hg in open cardiac compression compared to only 20.3 mm Hg with closed chest compressions.[14] Many animal studies consistently demonstrate this.[15][16] Furthermore, cerebral perfusion also concordantly improves with open cardiac massage and approaches near-normal values, whereas closed chest compressions lead to only 30% of normal cerebral blood flow.[17]

One of the primary human studies performed by Boczar and colleagues in 1995 showed that coronary perfusion pressure increased from an average of 7.3 mm Hg to 32.6 mm Hg when converting from closed chest compressions to open chest direct cardiac compressions.[18] Furthermore, mean cardiac index values more than double with direct open compressions.[19]

Very few human trials studying outcomes of open cardiac massage have been published. Most recently, in 2011, a study of 76 patients who experienced cardiac arrest after coronary artery bypass grafting surgery, demonstrated a survival rate of 82% after immediate resternotomy with open cardiac massage.[20] Another study in non-traumatic, out-of-hospital, cardiac arrest showed the return of spontaneous circulation in 58% of patients in the open chest compression group, versus only 30% in the closed chest compression group.[21]

Despite these reassuring findings, these data must be interpreted with caution as the intervention of chest compression may be performed too late, and many include a unique population of patients who underwent recent cardiac surgery.


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Open Heart Massage - Questions

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During an emergency room thoracotomy, a two-handed heart massage is undertaken to revive the patient. How long should the resuscitation be continued this way?



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A 65-year-old male patient who status-post emergent thoracotomy for penetrating wound injury was resuscitated with open cardiac massage. His wounds were closed, but continued bleeding was suspected. Which of the following arteries is the least likely source of bleeding?



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In terms of physiology, open cardiac massage in human studies is not associated with which of the following compared to closed chest compressions?



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An 85-year-old male with a history of coronary artery disease status post-CABG, chronic pain, recurrent Clostridium difficile infections, and most recently open cardiac surgery for aortic and mitral valve replacement experienced cardiac arrest in the post-anesthesia care unit. A repeat thoracotomy with subsequent open cardiac massage is performed with return of spontaneous circulation. Which of the following does not comprise the next steps?



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Which of the following does not adhere to the proper technique for open cardiac massage?



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Open Heart Massage - References

References

Kornhall DK,Dolven T, Resuscitative thoracotomies and open chest cardiac compressions in non-traumatic cardiac arrest. World journal of emergency surgery : WJES. 2014     [PubMed]
Bradley MJ,Bonds BW,Chang L,Yang S,Hu P,Li HC,Brenner ML,Scalea TM,Stein DM, Open chest cardiac massage offers no benefit over closed chest compressions in patients with traumatic cardiac arrest. The journal of trauma and acute care surgery. 2016 Nov     [PubMed]
Vallejo-Manzur F,Varon J,Fromm R Jr,Baskett P, Moritz Schiff and the history of open-chest cardiac massage. Resuscitation. 2002 Apr     [PubMed]
Böhrer H,Goerig M, Early proponents of cardiac massage. Anaesthesia. 1995 Nov     [PubMed]
Lee WE,Downs TM, RESUSCITATION BY DIRECT MASSAGE OF THE HEART IN CARDIAC ARREST. Annals of surgery. 1924 Oct     [PubMed]
Wise D,Davies G,Coats T,Lockey D,Hyde J,Good A, Emergency thoracotomy:     [PubMed]
Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 6: advanced cardiovascular life support: 7C: a guide to the International ACLS algorithms. The American Heart Association in collaboration with the International Liaison Committee on Resuscitation. Circulation. 2000 Aug 22     [PubMed]
Morgan BS,Garner JP, Emergency thoracotomy--the indications, contraindications and evidence. Journal of the Royal Army Medical Corps. 2009 Jun     [PubMed]
Alifimoff JK, Open versus closed chest cardiac massage in non-traumatic cardiac arrest. Resuscitation. 1987 Mar     [PubMed]
Safar P, Cerebral resuscitation after cardiac arrest: research initiatives and future directions. Annals of emergency medicine. 1993 Feb     [PubMed]
STEPHENSON HE Jr,REID LC,HINTON JW, Some common denominators in 1200 cases of cardiac arrest. Annals of surgery. 1953 May     [PubMed]
BRIGGS BD,SHELDON DB,BEECHER HK, Cardiac arrest; study of a thirty-year period of operating room deaths at Massachusetts General Hospital, 1925-1954. Journal of the American Medical Association. 1956 Apr 28     [PubMed]
Benson DM,O'Neil B,Kakish E,Erpelding J,Alousi S,Mason R,Piper D,Rafols J, Open-chest CPR improves survival and neurologic outcome following cardiac arrest. Resuscitation. 2005 Feb     [PubMed]
Kern KB,Sanders AB,Badylak SF,Janas W,Carter AB,Tacker WA,Ewy GA, Long-term survival with open-chest cardiac massage after ineffective closed-chest compression in a canine preparation. Circulation. 1987 Feb     [PubMed]
Sanders AB,Kern KB,Ewy GA,Atlas M,Bailey L, Improved resuscitation from cardiac arrest with open-chest massage. Annals of emergency medicine. 1984 Sep     [PubMed]
Byrne D,Pass HI,Neely WA,Turner MD,Crawford FA Jr, External versus internal cardiac massage in normal and chronically ischemic dogs. The American surgeon. 1980 Dec     [PubMed]
Boczar ME,Howard MA,Rivers EP,Martin GB,Horst HM,Lewandowski C,Tomlanovich MC,Nowak RM, A technique revisited: hemodynamic comparison of closed- and open-chest cardiac massage during human cardiopulmonary resuscitation. Critical care medicine. 1995 Mar     [PubMed]
DELGUERCIO LR,FEINS NR,COHN JD,COOMARASWAMY RP,WOLLMAN SB,STATE D, COMPARISON OF BLOOD FLOW DURING EXTERNAL AND INTERNAL CARDIAC MASSAGE IN MAN. Circulation. 1965 Apr     [PubMed]
Karhunen JP,Jokinen JJ,Raivio PM,Salminen US, Long-term survival and quality of life after cardiac resuscitation following coronary artery bypass grafting. European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery. 2011 Jul     [PubMed]
Takino M,Okada Y, The optimum timing of resuscitative thoracotomy for non-traumatic out-of-hospital cardiac arrest. Resuscitation. 1993 Aug     [PubMed]
Schnüriger B,Studer P,Candinas D,Seiler CA, Transdiaphragmatic resuscitative open cardiac massage: description of the technique and a first case-series of an alternative approach to the heart. World journal of surgery. 2014 Jul     [PubMed]

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