Introduction:
Surgical aortic valve replacement (SAVR) has been the gold standard
treatment for severe aortic stenosis for the past several decades and
remains one of the most commonly performed operations for the practicing
adult cardiac surgeon.1 Despite SAVR being a
relatively standard operation, it is not without significant risk to the
patient. This risk is attributed to, in part, by the innate invasiveness
of the procedure and the comorbidities common within the patient
population. SAVR also carries a well-known risk of shedding debris into
the left ventricle during aortic valve leaflet excision and annulus
debridement. Embolization of this debris into systemic circulation may
cause a wide range of complications including ischemic complications of
the brain, visceral organs, and extremities.2 Recent
meta-analyses concerning early postoperative complications for SAVR
indicate that 58% of patients experience a silent brain infarct and
5.1% of patients experience a TIA or stroke as a sequelae of this
procedure.2-3 These complications may have devastating
effects on the lives of patients, and the surgeon must take it upon
themself to mitigate these risks to patients.
Numerous techniques have been developed to capture debris developed
during aortic valve leaflet removal and annulus debridement. Most
commonly, delicate surgical debridement, left ventricular irrigation
with suctioning, and insertion of intraventricular surgical sponges have
been employed for this purpose.4 Several additional
techniques exist that are often practice specific and the superiority of
specific approaches is a contentious and hotly debated topic. Though
numerous techniques exist, no objective data currently exists in the
literature to address their relative efficacy. The value of these
techniques has recently been called into question. For example, our
group recently published an ex-vivo porcine model evaluating the
efficacy of left ventricle irrigation and careful suctioning to capture
debris. Debris of varying density (limestone pieces, pledgets, and
tissue) were placed inside the left ventricle (LV) and the LV was
thoroughly irrigated and suctioned numerous times. The resulting
solutions were filtered and the debris within them was quantified. It
was found that the rate of debris capture was relatively low, 43% of
pledgets, 17% of limestone, and 9% of tissue pieces were
retrieved.4 Given the devastating nature of these
complications, the individual and relative efficacy of each technique
aimed at capturing calcified debris during SAVR should be objectively
evaluated, compared, and a best practice standard should be developed
for use across the specialty.
The insertion of a surgical sponge into the left ventricle prior to
aortic valve leaflet excision and annulus debridement is a simple and
cost-effective method for capturing debris developed during SAVR (Figure
1).5 Herein, we present a prospective case series
aimed at objectively evaluating the efficacy of this technique in
capturing debris via gross, radiographic, and histological examination
of surgical specimens.