From the Guidelines
Open cardiac massage is indicated in cardiac arrest due to massive pulmonary embolism when standard resuscitation efforts fail and immediate surgical intervention is possible, as it may improve outcomes in this highly lethal condition. This recommendation is based on the understanding that massive pulmonary embolism (PE) can lead to cardiac arrest with a high mortality rate, ranging from 65% to 90% [ 1 ]. The management of acute PE is determined by disease severity, and fulminant PE, characterized by cardiac arrest or severe hemodynamic instability, requires prompt and aggressive treatment [ 1 ].
Key considerations for open cardiac massage in this context include:
- The procedure should be considered when conventional closed chest compressions are ineffective, especially in cases where the pulmonary embolism has caused obstructive shock [ 1 ].
- Timing is critical, with the decision to perform open cardiac massage ideally made within 10 minutes of arrest, as neurological outcomes worsen with delays.
- The procedure requires a skilled surgeon and should be performed in conjunction with other interventions such as thrombolysis (if not contraindicated), anticoagulation, and mechanical ventilation [ 1 ].
- The potential benefit of restoring circulation must be weighed against the significant trauma of the procedure and should be considered only when the alternative is certain death.
In the context of real-life clinical medicine, the priority is to minimize morbidity, mortality, and improve quality of life. Given the high mortality associated with cardiac arrest due to massive PE, open cardiac massage should be considered as a lifesaving measure when standard treatments fail and the patient's condition warrants aggressive intervention. This approach aligns with the 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care, which emphasizes the importance of prompt and effective treatment for fulminant PE [ 1 ].
From the Research
Indications for Open Cardiac Massage in Cardiac Arrest due to Massive Pulmonary Embolism
- There is no direct evidence to support the use of open cardiac massage as a primary treatment for cardiac arrest caused by massive pulmonary embolism 2, 3, 4, 5, 6.
- The current treatment guidelines recommend reperfusion therapy with systemic thrombolytics, such as tenecteplase or alteplase, in addition to anticoagulation for high-risk pulmonary embolism 6.
- Extracorporeal membrane oxygenation (ECMO) may be used as a lifesaving measure to provide hemodynamic and respiratory support in critically ill patients with massive pulmonary embolism leading to cardiac arrest 3, 4.
- Surgical embolectomy may be considered in some cases, particularly when the duration of cardiac arrest is short 2.
Alternative Treatment Options
- Systemic thrombolytic therapy has been shown to be beneficial in cardiac arrest due to acute pulmonary embolism 5.
- VA-ECMO and VV-ECMO are two different modes of ECMO that can be used to assist patients with massive pulmonary embolism leading to cardiac arrest 4.
- Percutaneous cardiopulmonary support (PCPS) may be a useful tool for stabilizing the patient and providing a bridge when deciding on further management options 2.