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 Case of a Commando Operation with One Boat-Shaped Bovine Pericardial Patch for Active Infective Endocarditis / 日本心臓血管外科学会雑誌

An 82-year-old man was referred to our hospital because of fever and disequilibrium. Brain magnetic resonance imaging showed acute multiple cerebral infarctions with multiple small intracerebral hemorrhages. The laboratory tests revealed an elevated inflammatory response, and two separate sets of blood cultures were positive for Streptococcus oralis. Transesophageal echocardiography revealed a single site of vegetation (13×11 mm) of the mitral anterior annulus. The vegetation apparently did not involve the intervalvular fibrous body. Moderate mitral regurgitation and mild to moderate aortic regurgitation were detected. Early surgical intervention was considered, but there was a high risk of operative mortality. We thus initially performed only medical treatment. Transesophageal echocardiography was again performed 12 days after his admission and revealed vegetation of the mitral anterior annulus progressing to the aortic annulus via the intervalvular fibrous body. It seemed to be difficult to control this progressive infective endocarditis with medical treatment. We therefore performed a semi-urgent operation. With an incision into the right-side left atrium, we identified the vegetation of the center of the mitral anterior leaflet progressing to the mitral anterior annulus. Subsequently, we added an aortotomy with Manouguian’s incision. We were able to remove all vegetation that was present in the aortic annulus, intervalvular fibrous body, and mitral annulus with a Commando operation. Finally, we performed double valve replacement with reconstruction of the intervalvular fibrous body and other lost cardiac structures using one boat-shaped bovine pericardial patch. He was discharged to home 34 days after surgery with no neurological complications and no recurrence of infective endocarditis. He also had no recurrence of infective endocarditis and no paravalvular leakage on either prosthetic valve at one year after the surgery.

Modification of reconstruction of left ventricular outflow tract, aortic root and the intervalvular fibrous body for extensive infective endocarditis: a single-centre experience.

OBJECTIVES: Extensive infective endocarditis (IE) stays a serious life-threatening disease with high mortality and morbidity. The aim of this study is to analyse our experience with our modified surgical technique for extensive IE during the last 4 years. METHODS: Between March 2017 and February 2021, all patients with extensive IE required our modified technique consisting of a radical surgical resection of all infected cardiac tissues, the replacement of infected valves and a reconstruction of the intervalvular fibrous body, the aortic root and the left ventricular outflow tract with modified elephant trunk were included in this study. RESULTS: Our modified technique was performed on 41 patients during the study period. The age median was 74 [interquartile range (IQR): 66.5-76.5] and 61.0% (n = 25) were female. Thirty-three patients (80.5%) were in New York Heart Association Class III-IV and 7 patients (17.1%) in cardiogenic shock. The median logistic European system for cardiac operative risk evaluation II as predicted risk of mortality was 35% (IQR: 28-78%). The median cardiopulmonary bypass time and cross-clamping time were 126 (IQR: 86.5-191) and 78 (IQR: 55.5-108) min, respectively. Intraoperative mortality and 30-day mortality were 4.8% (2 patients) and 19.5% (8 patients), respectively. Low cardiac output with necessity for mechanical support, stroke and new renal dialysis developed in 9.8% (4 patients), 17.1% (7 patients) and 22.0% (9 patients), respectively. New pacemaker implantation was noted in 39.0% (16 patients). Intensive care stay and hospital stay had medians of 6 (IQR: 5-12) and 14 (IQR: 12.5-20.5) days, respectively. One-year mortality and 4-year mortality were 34.1% (14 patients) and 39.0% (16 patients), respectively. Kaplan-Meier survival estimates were 60.3% (95% confidence interval: 46.2-78.6%) at 3 years. CONCLUSIONS: Our modified technique can be performed in patients with extensive IE with acceptable early and mid-term morbidity and mortality. We believe that this technique is an available option for this ill-fated group of patients.

Outcomes of combined aortic and mitral valve replacement with reconstruction of the fibrous skeleton of the heart.

OBJECTIVES: The objectives of this study were to examine operative and long-term results of combined aortic and mitral valve replacement when reconstruction of the fibrous skeleton of the heart is needed because of calcification, abscess, previous operations, or patient-prosthesis mismatch. METHODS: From 1985 to 2020, 182 consecutive patients underwent combined aortic and mitral valve replacement with reconstruction of the intervalvular fibrous skeleton in all cases and also the posterior mitral annulus in 63 patients. Bovine pericardium or Dacron grafts were used for the reconstructions. Median follow-up was 7.5 (interquartile range, 2.1-12.6) years and 98% complete. RESULTS: Patient mean age was 62 years; 69% had 1 or more previous valve operations, and 92% were functional class III or IV. The indications for reconstruction were extensive calcification of the fibrous skeleton in 34%, abscess in 13%, tissue damage secondary to previous operations in 39%, and patient-prosthesis mismatch of the mitral valve in 13%. Bovine pericardium was used in two-thirds of cases and Dacron grafts in one-third. Operative mortality was 13.2% and postoperative complications were common. Survival at 1, 10, and 20 years was 81.8%, 51.1%, and 23.7%, respectively. Fourteen patients required reoperation and 3 transcatheter interventions. The cumulative probability of reinterventions at 1, 10, and 20 years were 3.3%, 5.8%, and 9.1%, respectively. Most patients experienced symptomatic improvement postoperatively. CONCLUSIONS: Reconstructions of the fibrous skeleton of the heart are associated with high operative mortality but the long-term results are satisfactory because most patients would not have survived without surgical intervention.

Modified commando procedure in complicated infective endocarditis ─ a case series.

BACKGROUND: Complicated infective endocarditis (IE) with perivalvular abscess and destruction of intervalvular fibrous body (IFB) has high mortality risk and requires emergent or urgent surgery mostly. CASE PRESENTATION: We presented four patients with complicated infective endocarditis combined with perivalvular abscess and IFB destruction. Three patients had prosthetic valve endocarditis and one patient had native valve endocarditis. They all received modified Commando procedure successfully. No surgical mortality or re-exploration for bleeding. CONCLUSIONS: We suggest that modified Commando procedure may have some benefit in improving survival rate of patients with complicated IE and reducing complications.

Prosthetic valve detachment complicated with intervalvular fibrous body destruction in Behcet's disease: a case report.

BACKGROUND: Prosthetic valve detachment is not rare after aortic valve replacement in Behcet's disease. However, destruction of the intervalvular fibrous body (IFB) due to Behcet's disease was rarely reported. CASE PRESENTATION: We report a case of 30 year-old woman, with valve detachment and IFB separation. The patient received aortic valve replacement three months ago. Her medical history included recurrent oral ulcers and cutaneous lesions. Finally, reoperation was performed and peri-operative steroid therapy was carried out. CONCLUSIONS: The case presented a rare complication of valve detachment in Behcet's disease.

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.

Five-year outcomes following complex reconstructive surgery for infective endocarditis involving the intervalvular fibrous body.

OBJECTIVES: Destruction of the intervalvular fibrous body (IFB) due to infective endocarditis (IE) warrants a complex operation involving radical debridement of all infected tissue, followed by double valve replacement (aortic and mitral valve replacement) with patch reconstruction of the IFB. This study assesses the 5-year outcomes in patients undergoing this complex procedure for treatment of double valve IE with IFB involvement. METHODS: A total of 127 consecutive patients underwent double valve replacement with reconstruction of the IFB for active complex IE between January 1999 and December 2018. Primary outcomes were 3-year and 5-year survival, as well as 5-year freedom from reoperation. RESULTS: Patients' mean age was 65.3 ± 12.9 years. Preoperative cardiogenic shock and sepsis were present in 17.3% and 18.9%, respectively. The majority of patients (81.3%) had undergone previous cardiac surgery. Overall, 30-day and 90-day mortality rates were 28.3% and 37.0%, respectively. The 3- and 5-year survival rates for all patients were 45.3 ± 5.1% and 41.8 ± 5.8%, and for those who survived the first 90 postoperative days 75.8 ± 6.1% and 70.0 ± 8.0%, respectively. The overall 5-year freedom from reoperation was 85.1 ± 5.7%. Preoperative predictors for 30-day mortality were Staphylococcus aureus [odds ratio (OR) 1.65; P = 0.04] and left ventricular ejection fraction (LVEF) <35% (OR 12.06; P = 0.03), for 90-day mortality acute kidney injury requiring dialysis (OR 6.2; P = 0.02) and LVEF <35% (OR 9.66; P = 0.03) and for long-term mortality cardiogenic shock (hazard ratio 2.46; P = 0.01). CONCLUSIONS: Double valve replacement with reconstruction of the IFB in patients with complex IE is a challenging operation associated with high morbidity and mortality, particularly in the first 90 days after surgery. Survival and freedom from reoperation rates are acceptable thereafter, particularly considering the severity of disease and complex surgery.

Successful surgical treatment for total circumferential aortic and mitral annulus calcification: application of half-and-half technique.

Patients with total circumferential mitral annular calcification (MAC) extending into the intervalvular fibrous body and aortic annulus have a high risk of cardiac surgery, which remains a technical challenge for surgeons. Our technique for MAC is characterized as simple supra-mitral annular prosthesis insertion after minimum debridement of calcification ("half-and-half technique"). To date, our technique has been applied in only simple MAC cases and has good results. Herein, we report successful two cases of total circumferential MAC, extending into the intervalvular fibrous body and aortic annulus that were treated by a simple double valve replacement with application of our "half-and-half technique".

Aortic and Mitral Valve Replacements in a Patient with Extensive Calcification of Intervalvular Fibrous Body / 日本心臓血管外科学会雑誌

Extensive calcification of the mitral annulus presents a formidable technical challenge to surgeons and increases the risk of serious complications such as intractable hemorrhage, atrioventricular disruption, and ventricular rupture during mitral valve surgery. We present a case of aortic and mitral valve replacements for a patient with extensive calcification of an intervalvular fibrous body. A 76-year-old woman was admitted with dyspnea on effort, leg edema and syncope. Transthoracic echocardiography showed severe aortic stenosis, and mitral stenosis with regurgitation, and extensive mitral annular calcification. Decalcification was performed with CUSA and we selected a trans-aortic-valve approach for decalcification of the intervalvular fibrous body. The calcification was left to a certain extent in order to preserve annular strength. Postoperative echocardiography showed no perivalvular leakage from either prostheses. The patient was transferred to a local hospital for further rehabilitation.