DIRECT CARDIAC MASSAGE WITHOUT MAJOR THORACOTOMY - FEASIBILITY AND SYSTEMIC BLOOD-FLOW

Background: Open-chest cardiac massage (OC-CM) provides higher blood pressure and flow than closed-chest compression and may improve the probability of successful resuscitation from cardiac arrest. Its clinical use has been limited by its requirement for a major thoracotomy. The present pilot study tested the technical feasibility of performing effective direct cardiac massage without a major thoracic incision, by using a simple, manually-powered plunger-like device, inserted through a small thoracic incision, to cyclically compress the cardiac ventricles. The method was termed minimally-invasive direct cardiac massage (MID-CM). Systemic blood flow using MID-CM was compared to that with OC-CM, by both direct systemic hemodynamic measurements, cumulative metabolic indicators of the ratio of whole body oxygen delivery and oxygen consumption, and a metabolic index of pulmonary blood flow. Methods: In 12 large swine, baseline systemic and pulmonary hemodynamic measurements were performed. Arterial and mixed venous blood gases and metabolic indicators of systemic blood flow were measured. Ventricular fibrillation was induced and after 4 min, animals underwent either bimanual OC-CM (N=6) or MID-CM (N=6). At 10, 20 and 30 min, hemodynamic and metabolic measurements were repeated. Results: Systemic Blood Pressure: Aortic systolic and diastolic blood pressures were reduced from baseline levels with both OC-CM and MID-CM. No difference in pressure was noted between OC-CM and MID-CM groups. Pulmonary Artery Pressure: Pulmonary artery systolic pressure was elevated from baseline during OC-CM and MID-CM. Pulmonary artery diastolic pressures remained constant throughout the resuscitation period in both groups. No differences in pulmonary systolic or diastolic pressure were noted between OC-CM and MID-CM groups. A trend towards higher pulmonary systolic pressures appeared with MID-CM. Thermodilution Blood Flow: Cardiac index fell from baseline levels with OC-CM and MID-CM. No difference in cardiac index was noted between OC-CM and MID-CM groups. Metabolic Indices: Mixed venous O-2 saturation decreased from baseline levels during resuscitation in both experimental groups, with a further decrease at 30 min compared to 10- and 20-min levels. No difference was noted between OC-CM and MID-CM groups at any point. Arterial pH was reduced from baseline levels at 30 min in both groups compared to baseline but no difference was noted between groups. Arterio-venous PcO(2) difference increased above baseline levels with both OC-CM and MID-CM. No difference was noted between groups. Lactate levels displayed a progressive increase up to 30 min in both groups compared to baseline. No differences were noted between OC-CM and MID-CM groups for any time-period. Conclusions: Direct cardiac massage without major thoracotomy is technically feasible. The level of systemic blood flow that can be achieved with MID-CM is hemodynamically and metabolically equivalent to that obtained using conventional bimanual OC-CM.