Reconstruction of Fibrous Skeleton of the Heart for Double-Valve Replacement in A Pediatric Patient - Modified Commando Procedure.

The so-called Commando procedure, initially described by David and colleagues, consists in the reconstruction of the mitro-aortic fibrous lamina by a patch that enlarges both annuli. Its use has been described to upsize the aortic and mitral annulus for double valve replacement in adolescents. We describe a modified technique of this reconstruction of the fibrous skeleton of the heart, combined with Konno procedure to further enlarge the aortic annulus. In modified Commando procedure, following the reconstruction of aortomitral continuity with a bovine pericardium CardioCel patch (Admedus Regen Pty Ltd, Perth, WA, Australia), an aortic valved conduit that was made on the bench in order to have bottom skirt that enabled the suturing of the composite conduit far inside the left ventricle outflow tract. Coronary buttons were implanted at the supra-commissural level. The advantages of this modified Commando procedure are (1) the creation of a new aortic annulus when the integrity of this annulus has been compromised, (2) the upsizing of both annuli to any possible size of aortic and mitral prostheses, and (3) the relief of any residual left ventricular outflow tract obstruction.

Modified Commando procedure using a double valve composite through an aorto-annulo-septotomy.

Double valve replacement of aortic and mitral valves with intervalvular fibrous body reconstruction (Commando procedure) is a challenging operation. Particularly in redo surgery for prosthetic valve endocarditis, special techniques are needed for approaching and reconstructing the valve complex. We performed a modified Commando procedure using a double valve composite through an aorto-annulo-septotomy. This approach provided a good field of vision at the combined aortic and mitral annuli without incising the left atrial roof. The double valve composite with four-layer patch wings was useful for performing double valve replacement en bloc and aorto-annulo-septotomy closure serially. Using these techniques, we successfully performed the Commando procedure for complicated prosthetic valve endocarditis.

A surgically salvaged case: emergency Root-Commando procedure for infective endocarditis and chronic dissecting aneurysm of the sinus of Valsalva.

The Commando procedure for infective endocarditis is a high-risk intervention. However, infective endocarditis involving the intervalvular fibrosa is fatal in the absence of surgery. A 41-year-old man with no medical history visited a doctor with chest pain and dyspnoea. Ascending aortic dissection and vegetation on the mitral valve were noted on echocardiography, so he was transferred to our hospital. The diagnosis was dissecting aneurysm of the sinus of Valsalva and acute heart failure due to aortic regurgitation, mitral regurgitation and infective endocarditis. We decided on emergency surgery. Intraoperatively, we confirmed abscess extending to the left atrial roof and destruction of the intervalvular fibrosa, so we performed the Root-Commando procedure. The patient was saved and discharged 47 days after transfer to our hospital through the reoperation on postoperative day 30.

Surgical Challenges in Infective Endocarditis: State of the Art.

Infective endocarditis (IE) is still a life-threatening disease with frequent lethal outcomes despite the profound changes in its clinical, microbiological, imaging, and therapeutic profiles. Nowadays, the scenario for IE has changed since rheumatic fever has declined, but on the other hand, multiple aspects, such as elderly populations, cardiovascular device implantation procedures, and better use of multiple imaging modalities and multidisciplinary care, have increased, leading to escalations in diagnosis. Since the ESC and AHA Guidelines have been released, specific aspects of diagnostic and therapeutic management have been clarified to provide better and faster diagnosis and prognosis. Surgical treatment is required in approximately half of patients with IE in order to avoid progressive heart failure, irreversible structural damage in the case of uncontrolled infection, and the prevention of embolism. The timing of surgery has been one of the main aspects discussed, identifying cases in which surgery needs to be performed on an emergency (within 24 h) or urgent (within 7 days) basis, irrespective of the duration of antibiotic treatment, or cases where surgery can be postponed to allow a brief period of antibiotic treatment under careful clinical and echocardiographic observation. Mainly, guidelines put emphasis on the importance of an endocarditis team in the handling of systemic complications and how they affect the timing of surgery and perioperative management. Neurological complications, acute renal failure, splenic or musculoskeletal manifestations, or infections determined by multiresistant microorganisms or fungi can affect long-term prognosis and survival. Not to be outdone, anatomical and surgical factors, such as the presence of native or prosthetic valve endocarditis, a repair strategy when feasible, anatomical extension and disruption in the case of an annular abscess (mitral valve annulus, aortic mitral curtain, aortic root, and annulus), and the choice of prosthesis and conduits, can be equally crucial. It can be hard for surgeons to maneuver between correct pre-operative planning and facing unexpected obstacles during intraoperative management. The aim of this review is to provide an overview and analysis of a broad spectrum of specific surgical scenarios and how their challenging management can be essential to ensure better outcomes and prognoses.

Early outcomes of the "Chimney" commando procedure in the small aortic and mitral annuli.

Background: Commando procedure, the surgical replacement of the mitral and aortic valves combined with reconstruction of the fibrosa fibrous body, is a technical challenge in patients with small aortic and mitral annuli. In this study, we evaluated the safety and early outcomes of the "Chimney" modality of the Commando procedure, in patients with small aortic and mitral annuli, after prior valve surgery, using a self-assembled valved conduit. Methods: From April 2021 to April 2022, 30 consecutive cases of the "Chimney" Commando procedure, with a self-assembled valved conduit and other combined cardiac procedures, were fully performed for re-operative patients with small aortic roots. Data were obtained through a medical record review, at the Asian Heart Hospital in Wuhan, China. Results: The patient's mean age was 52.7 ± 13.53 years, with 93.3% females. All patients had a previous heart valve surgery, 90% of which had double valve replacement (DVR). Hospital death occurred in 3.3% (n = 1) of the patients, due to malignant arrhythmias and multiorgan failure. Postoperative echocardiogram exams showed that the sizes of the aortic and mitral valve prostheses were 24.23 ± 1.60 mm and 28.33 ± 1.21 mm, respectively. All patients had intact intervalvular fibrosa (IVF) repair and no patient had any aberration in the left heart chamber communication. With the exception of one postoperative sick sinus syndrome and one re-sternotomy for bleeding, there were no significant postoperative complications, such as mortality, renal failure requiring ongoing dialysis, or mediastinitis. Echocardiography exams in the sixth postoperative month showed that the mean gradients of the aortic and mitral valves were 16.26 ± 6.44 mmHg and 11.24 ± 4.90 mmHg, respectively. Conclusions: In comparison with the standard Commando operation, the early outcomes and safety of the "Chimney" Commando procedure proved to be a feasible therapeutic option for patients with small aortic and mitral annuli, after prior valve operations. This approach enables the enlargement of the aortic and mitral annuli and the implantation of the necessary valve prosthesis.

The Commando procedure for pediatric patients: A case series.

Objective: The Commando procedure involves division of the intervalvular fibrous body, mitral valve replacement, and aortic valve replacement. It is considered a technically challenging procedure and traditionally has had high mortality. Methods: Five pediatric patients with combined left ventricular inflow and outflow obstruction were included in this study. Results: There were no early or late deaths during follow-up, and no pacemakers were implanted. None of the patients required reoperation during follow-up, and none developed a clinically significant gradient across the mitral valve or aortic valve. Conclusions: The risks of this operation for patients with congenital heart disease undergoing multiple redo operations should be weighed against the benefits of normal-size mitral and aortic annular diameters and dramatically improved hemodynamics.

Aorto-mitral curtain reconstruction in invasive double-valve endocarditis: mid-term outcomes.

Background: Invasive double-valve endocarditis with structural damage (abscess or perforation) of the aorto-mitral curtain is a relatively rare but fatal diagnosis requiring complex surgical reconstruction. This study presents the short-term and mid-term outcomes from a single center. Methods: From 2014 to 2021, 20 patients with double-valve endocarditis with structural damage of the aorto-mitral curtain underwent surgical reconstruction (Hemi-Commando procedure n = 16 and Commando procedure n = 4). Data were obtained retrospectively. Results: In 13 cases, the procedure was a reoperation. The mean cardiopulmonary bypass time was 239 ± 47 min and the mean cross-clamp time was 186 ± 32 min. Concomitant procedures were tricuspid valve repair in two, coronary revascularization in one, closure of a ventricular septal defect in one and hemiarch (using circulatory arrest) in one patient. Eleven patients (55%) required surgical revision for bleeding. Thirty-day mortality was 30% (6 patients)-3 patients from the Hemi-Commando group (19%) and 3 patients from the Commando group (75%). Overall survival at 1, 3 and 5 years was 60%, 50% and 45% respectively. Reoperation was required by 4 patients. Freedom from reoperation at 1, 3 and 5 years was 86%, 71% and 71% respectively. Conclusion: Despite the high postoperative morbidity and mortality, complex surgical reconstruction of the aorto-mitral continuity of patients with double-valve endocarditis represents the only real chance for survival. Mid-term outcomes are acceptable, but strict follow-up is required due to the risk of valve failure.

A rare complication of double prosthetic valve endocarditis; reconstructive surgical treatment of mitral-aortic intervalvular fibrosa pseudoaneurysm and left atrial fistula.

Mitral aortic intervalvular fibrosa or aorto-mitral curtain is a fibrous avascular skeletal structure located between the anterior leaflet of the mitral valve and the non-coronary and left coronary cusps of the aortic valve. Mitral and aortic valve endocarditis are rarely accompanied by mitral aortic intervalvular fibrosa pseudoaneurysm and left atrial fistula of the aorta. Pseudoaneurysm of mitral aortic intervalvular fibrosa is a fatal complication that can occur after valvular surgery, valvular endocarditis, or blunt trauma. In this article, reconstructive surgical management with the Commando technique of a case who developed mitral-aortic intervalvular fibrosa pseudoaneurysm to left atrial fistula after aortic and mitral prosthetic valve endocarditis is described. The important feature of this article is that it is a first in the literature as it is accompanied by persistent left superior vena cava.

Impact of advanced imaging techniques on preoperative planning in cardiac surgery.

BACKGROUND AND AIM OF THE STUDY: Review how advanced imaging techniques and a multidisciplinary heart team approach are used to evaluate complex cardiac structural pathology. METHODS: Single-center retrospective case series. RESULTS AND CONCLUSIONS: Cardiac computed tomography angiography in addition to transthoracic and transesophageal echocardiography impacts pre-procedural planning and procedural success.

Refractory Salmonella Prosthetic Valve Endocarditis Complicated by Splenic Infarction and Aortic Pseudoaneurysm in a Patient with Double Prosthetic Valves: A Case Report.

Endocarditis is an extremely rare complication of Salmonellosis with an incidence of 0.2-0.4%. It is a destructive and invasive infection that follows a highly complicated course and carries a high mortality rate that exceeds 45%. Multiple predisposing factors for Salmonella endocarditis have been described in the literature, including human immunodeficiency virus infection, congenital heart diseases, and the presence of a prosthetic valve. Herein, we report a case of Salmonella prosthetic valve endocarditis complicated by splenic infarction and aortic pseudoaneurysm presenting as a month-long history of fluctuating fever, chills, and rigors, accompanied by occasional cough and shortness of breath in a 55-year-old female with aortic and mitral valves replacement and multiple comorbidities. She was diagnosed by multiple radiographic studies and successfully treated with the Commando procedure and a long course of IV antibiotics.

A novel patch-sparing technique for reconstruction of the aortomitral curtain.

Our goal was to describe a novel technique for reconstructing the aortomitral curtain using autologous tissue. This technique was performed on a patient who required replacement of both the aortic and mitral valves and the aortic root due to recurrent prosthetic valve infection and aortic root abscess. The aortomitral curtain was reconstructed without using any artificial patches. Instead, surrounding autologous tissues were used, including the residual healthy left atrial and aortic basal tissues. This patch-sparing technique may occasionally be feasible to perform and may serve as a secure anchor for subsequent aortic root replacement.

Repair of atrioventricular disruption after mitral valve replacement utilizing commando procedure principles.

Atrioventricular rupture is a life-threatening complication of mitral valve replacement. We present how incising the intervalvular fibrosa critically improves exposure. The aortic valve sacrifice allows access to a large atrioventricular dissociation defect and reliable repair of the anterolateral aspect of mitral valve annulus.

Left ventricular outflow tract to left atrial fistula: A rare long-term complication of the commando procedure.

The commando procedure involves aortic and mitral valve replacement with complete reconstruction of the aorto-mitral curtain. It is often a surgical treatment for invasive infective endocarditis with abscess, or less commonly for radiation-induced heart disease with extensive calcification extending from the aortic valve onto the anterior mitral leaflet. Prosthetic valve endocarditis is a known long-term complication of this surgery; however, reports of other long-term outcomes are limited. We report the case of a 59-year-old male who developed a non-infectious left ventricular outflow tract to left atrial fistula, incidentally found 5 years after undergoing a commando procedure for radiation-induced heart disease.

Surgical Aortic Mitral Curtain Replacement: Systematic Review and Metanalysis of Early and Long-Term Results.

The Commando procedure is challenging, and aims to replace the mitral valve, the aortic valve and the aortic mitral curtain, when the latter is severely affected by pathological processes (such as infective endocarditis or massive calcification). Given the high complexity, it is seldomly performed. We aim to review the literature on early (hospitalization and up to 30 days) and long-term (at least 3 years of follow-up) results. Bibliographical research was performed on PubMed and Cochrane with a dedicated string. Papers regarding double valve replacement or repair in the context of aortic mitral curtain disease were included. The metaprop function was used to assess early survival and complications (pacemaker implantation, stroke and bleeding). Nine papers (540 patients, median follow-up 41 (IQR 24.5-51.5) months) were included in the study. Pooled proportion of early mortality, stroke, pacemaker implant and REDO for bleeding were, respectively 16.2%, 7.8%, 25.1% and 13.1%. The long-term survival rate ranged from 50% to 92.2%. Freedom from re-intervention was as high as 90.9% when the endocarditis was not the first etiology and 78.6% in case of valvular infection (one author had 100%). Freedom from IE recurrences reached 85% at 10 years. Despite the high mortality, the rates of re-intervention and infective endocarditis recurrences following the Commando procedure are satisfactory and confirm the need for an aggressive strategy to improve long-term outcomes.

Essen-Commando: How we do it.

In rare cases of extensive aortic root or mitral valve infective endocarditis (IE), severe calcification of the aortic and mitral valves, or double-valve procedures in patients with small aortic and mitral annuli, surgical reconstruction of the intervalvular fibrous body (IVFB) is required. A high mortality is generally associated with this procedure, and it is frequently avoided by surgeons due to a lack of experience. It is crucial to radically resect all tissues that are severely affected by IE to prevent recurrence in the patient. Our experience with the Commando procedure in patients with extensive double-valve IE involving the IVFB is presented in this article.

An autopsy view of the Hemi-commando procedure.

Invasive endocarditis involving the fibrous skeleton of the heart requires complex high-risk surgical management. For combined aortic and mitral infection in whom the posterior mitral leaflet and at least the free edge of anterior mitral valve could be spared, a modification of the Commando procedure was suggested: the "Hemi-commando procedure." We report the autopsy images of a Hemi-commando procedure after in unfortunate death in a 24 years old man 17 days after surgery.

Aortic and mitral valve surgery for infective endocarditis with reconstruction of the intervalvular fibrous body: an analysis of clinical outcomes.

BACKGROUND: Reconstruction of the aorto-mitral curtain (AMC) for invasive double-valve infective endocarditis (IE) is a rare and challenging procedure. This study presents the short- and mid-term results of reconstruction of AMC in a single center. METHODS: From 2016 to 2019, 14 patients with invasive double-valve underwent surgical reconstruction of the AMC, along with either double valve replacement or aortic valve replacement with mitral valve repair. Two patients were diagnosed as Behcet's disease. Bicuspid aortic valve was detected in six patients. Mean follow up was 18.9±12.2 months. RESULTS: Positive blood culture was found in 10 (71.4%) patients: 3 of Abiotrophia defective (21.4%). The mean cardiopulmonary bypass (CPB) time was 154.5±25.9 minutes and the mean cross-clamp time was 116.8±18.2 minutes. One patient died of multiple organ failure (7.1%) 60 days after surgery. There was 1 (7.1%) case of stroke, 1 (7.1%) of atrioventricular block with pacemaker implantation, 1 (7.1%) of reoperation for bleeding. There was no late death during follow-up. The survival at 3 years was 92.9%. Freedom from reoperation at 1, 2, and 3 years was 100%, 100%, and 100% during follow-up, respectively. CONCLUSIONS: The double-valve replacement and AMC reconstruction (the Commando procedure) is an effective technique in complex heart valve disease. The short- and mid-term results with this technique are optimal, with a very low in-hospital mortality and nearly 100% of long-term survival during follow-up.