Patient Safety in Cardiothoracic Surgery: Enlightenment in the Tunnel of Danger

Letter to the Editor Dear Sir With great interest we read the original research paper by Shashank Shekhar et al. J Am Heart Assoc. 2024; 13:e034298. DOI: 10.1161/JAHA. 124.034298. The conclusion that Cerebral Protection Devices (CPD) used during transcatheter aortic valve replacement is not independently associated with a lower risk of overall stroke has not surprised us at all. Cardiothoracic surgeons and interventional cardiologists tend to underestimate the importance of specific information of the condition of the aorta and its carotid branches in relation with their contribution to cause serious cerebral events. Their focus is mainly targeted on cardiac repair and not necessarily on improving the outcome with regard to safety of the procedure. The industry has provided us with devices that helped us a lot further in the field and we are thankful for that. Many devices were developed with the help of a surgeon or even invented by a surgeon. A CPD may catch loosened particles or debris from the vessel wall or valve during the intervention. This short period of ‘cerebral protection’ disregards the potential risk due to damage at the time of inserting or placement of a device or cannula at different entry-sites of the vascular system. It thus sprinkles sand in the eyes of interventional team members: they think ‘the CPD will help me and my patients’. This is, to our opinion, a systemic error. We advocate using a multidisciplinary approach to anticipate on ‘hidden dangers’ in the main vascular tunnel and its cerebral branches to evaluate potential lethal embolic debris before even thinking of inserting or placement. First of all, we have to agree that there may be hidden dangers present, and secondly, we need to speak out loud: yes, we cannot close our eyes anymore for these findings and we need to do something with this information.