Introduction
Outcomes in out-of-hospital non-traumatic cardiac arrest have displayed marginal improvement since many decades. With a few notable exceptions, survival to discharge rates are less than 10% [
1]. Thus, it is exciting to see how future concepts in non-traumatic cardiac arrest management are constantly being developed and evaluated. One concept, though certainly not a new one, that frequently resurfaces in cardiac arrest literature is open chest cardiac massage [
2,
3]. Open chest cardiopulmonary resuscitation (OC-CPR) is the direct massage of the heart as opposed to the conventional closed chest cardiac compressions (CC-CPR). Numerous human and animal studies demonstrate how OC-CPR results in significantly improved hemodynamics and outcomes when compared to CC-CPR. Despite that, OC-CPR has not since the 1960s been considered a mainstream resuscitative intervention outside cardiac surgery and outside operating theatres.
This is partly explained by how the resuscitative thoracotomy, that allows access to the arrested heart, requires an operating theatre and controlled surgical conditions as it is an massively invasive intervention. Such dogma will inevitably delay initiating OC-CPR so that it’s benefits are lost. Animal studies indicate the benefits of OC-CPR are lost when direct cardiac massage is initiated after more than 20 minutes of cardiac arrest [
4]. Instead, CC-CPR has become the dominant intervention in non-traumatic cardiac arrest since it was popularised in the 1960s.
In contrast, resuscitative thoracotomies with OC-CPR are frequently performed in emergency departments in
traumatic cardiac arrest caused by thoracic injuries. Importantly, since about a decade, resuscitative thoracotomies are even performed outside hospitals. Air ambulance services have trained their clinicians to successfully perform thoracotomies in the prehospital setting for treating traumatic cardiac arrest [
5].
In light of that, perhaps it is time for thoracotomies and direct cardiac massage to refind their place in the resuscitation of non-traumatic cardiac arrest. By performing OC-CPR at a much earlier stage, in the emergency departments or even outside our hospitals, we could improve outcomes.
Open chest heart massage is not a novel concept. As a mainstream concept OC-CPR predates our gold standard CC-CPR by almost half a century. The method was first described on laboratory animals by professor Moritz Schiff in 1874. In 1901 norwegian physician Kristian Igelsrud performed the first successful resuscitation from cardiac arrest in a human subject using open chest compressions when a patient arrested during an elective hysterectomy [
6]. From then on, OC-CPR would for half a century remain the dominant method for cardiopulmonary resuscitation. Several large case series were published during that era proving the methods efficacy. In 1953 Stephenson et al. published a data from 1200 theatre cardiac arrests that had open chest CPR. The recovery rate was 28% [
7]. In 1954 Briggs et al. reported theatre cardiac arrest from the Massachusetts General Hospital during a 30 year period. In the patients where open chest CPR was initiated within 4 minutes, 58% recovered and were neurologically intact [
8]. To some extent this data can be compared to the Beth Israel outcomes study published in 1983. The authors, Bedell et al., reported survival rates of only 14% in patients who suffered in-hospital cardiac arrest who had closed chest compressions [
9].
Despite these promising findings, open chest compressions was about to be marginalised from the mainstream when, in the 1960s, Kouwenhoven et al. popularised closed chest compressions. In fairness, CC-CPR was described already in 1786 by Enfield surgeon John Sherwin, but it would remain an obscure method until the 1960s when closed chest compressions would become the gold standard for the layman on the street as well as for the resuscitation specialist. Since then, open chest compressions in non-traumatic cardiac arrest is rarely performed outside operating theatres or on postoperative care patients who recently had thoracotomies for cardiac surgery.