Is There A Role For Irrigation Of The Left Ventricle During Aortic Valve Surgery?
Hossein Amirjamshidi1, Jude S. Sauer2, Christopher J. Hand2, Peter A. Knight1.
1Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, NY, USA, 2LSI SOLUTIONS, Victor, NY, USA.
BACKGROUND: Stroke and post-op cognitive dysfunction following procedures involving the aortic valve and manipulation of the aorta are frequently attributed to emboli arising atherosclerotic plaque disruption. Despite no published supporting data, left ventricle (LV) irrigation is sometimes performed with aortic valve annular debridement to potentially reduce the risk of emboli. This ex-vivo heart model study evaluated whether irrigating the LV is effective at removing debris. METHODS: LV irrigation was performed in ex-vivo porcine hearts after debris of various densities, including limestone pieces, pledgets and tissue (cut pieces of aorta), was placed inside the LV. Debris retrieval rate was assessed following irrigation using a bulb syringe alone, irrigation followed by suction, and controlled irrigation using a novel system that enables manipulation of pressure, volume and direction of flow. Debris was filtered and counted. A bronchoscope was inserted through the left atrium or aorta to assess the LV during controlled irrigation and following its completion. RESULTS: With irrigation using a bulb syringe alone (15x), no pledgets, limestone pieces or tissue was ever removed in either Trendelenburg or reverse Trendelenburg position. An average of 6.7% of tissue pieces, no pledgets and no limestones were removed with irrigation followed by suction (5x). 41 tests of a customized irrigation system allowing for controlled changes in pressure, amount and direction of flow averaged 43% pledgets, 17% limestones and 9% tissue retrieval. Other observations: irrigant backflow deposited smaller limestone and tissue pieces into the left atrium (LA) and debris routinely appeared entrapped between papillary muscles and trabeculae. CONCLUSIONS: Results from this ex vivo porcine heart study demonstrate irrigation alone, regardless of augmentation with suction or heart positioning and use of a customized irrigation system, were not substantially effective for removing debris from the LV. Backflow of debris through the mitral valve into the LA was observed with irrigation. Better options and analysis are needed to progress our understanding of this critical concern for patients. 
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