Comment:
The results of our study demonstrate a high frequency of debris captured within surgical sponges placed in the left ventricle prior to aortic valve leaflet removal and annulus debridement. 75% of the sponges used in these procedures had some form of cellular or acellular debris contained within them on examination. 35% of sponges were grossly positive, 75% were radiographically positive, and 25% were histologically positive for calcified debris. The discrepancy between radiographic and histologic detection of calcified debris likely results from loss of the specimen during transfer or from under sampling the blocks from which microscopic slides are made. Alternatively, specimens may also contain surgical debris that is not mineralized. The results of this study are certainly encouraging with respect to this specific technique. However, this study was not designed to understand the possible clinical implications of embolization of the captured debris into systemic circulation. It is unclear if, for example, embolization of debris that is only able to be detected radiographically or histologically would have resulted in clinically significant complications for the patient. More data is needed to fully appreciate this relationship. Additionally, because calcified debris does not maintain its shape when cut for microscopic sections, our current methodological design cannot reliably estimate embolus size, though observed calcified debris ranged from 0.1 mm through 0.33 mm (Figure 3). However, we believe that consensus among practicing Cardiac Surgeons would support decreasing calcified debris of any size as a beneficial outcome for the patient.
This is the first published study aimed at objectively evaluating the efficacy of a technique for decreasing intravascular calcified debris in surgical aortic valve replacement. While the data in this proof-of-concept study is promising with respect to this technique, numerous additional techniques exist across practices and centers aimed at the same purpose. Given the devastating nature of these complications, the individual and relative efficacy of the prevention techniques should be objectively evaluated, compared, and a best practice standard should be developed for use across the specialty. To this end, additional data and multi-center collaboration is required.