Modified commando procedure in complicated infective endocarditis ─ a case series

Reoperative aortic root surgery: single-center long-term outcomes and literature review

Background and Objective

Reoperative aortic root surgery has become more and more common over the years and is considered high-risk, with significantly worse outcomes compared to first-procedure root surgery. At our institution, this kind of surgery is frequently performed. The aim of the present review is to describe currently available literature on reoperative surgery on the aortic root in terms of patients' population, indications for surgery and outcomes and to present our center's experience on the matter.

Methods

A literature review was performed in order to identify pertinent studies. They were then compared and described. We also described preoperative characteristics, operative strategies and outcomes of all the patients who underwent redo aortic root surgery from January 1986 to December 2022 at our center.

Key Content and Findings

Our literature review identified 12 pertinent studies, with a total of 16,627 considered patients. The most frequent indications for redo surgery were endocarditis (35.5%), aneurysm, dissection and pseudoaneurysm. Mean cardiopulmonary bypass (CPB) and cross-clamp times were 218 and 152 minutes, respectively. In-hospital mortality was 12%. When analyzing our center's data, 344 procedures were identified. Aortic root dilation was the most frequent indication (36.9%). Mean CPB and cross-clamp times were 218.0±78.8 and 158.2±49.7 minutes, respectively. In-hospital mortality was 9.6%. Survival at 5 and 15 years was 76.1% and 51.4% respectively. Freedom from further aortic reintervention was 88.1% after 5 years and 64.9% after 15 years.

Conclusions

Reoperative aortic root surgery is a difficult cardiac procedure which is linked to significantly higher mortality than first-time root replacement. If it is performed by experienced surgeons with a careful preoperative planning its result can still be satisfactory. Our results showed acceptable rates of mortality and reinterventions at follow-up. Endocarditis, however, was linked to worse outcomes.

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.

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.

"UFO procedure" for massive aortic and mitral annular calcification involving left atrial and ventricular myocardium: a potential radical solution

BACKGROUND

The "UFO procedure" was initially developed as a surgical option to enlarge the aortic annulus in patients requiring valve replacement. This technique can be employed to treat extensive endocarditis located in the intervalvular fibrous body (IVFB). One of the indications for a "UFO procedure" is massive aortic and mitral valve calcification. It is a challenging surgical procedure with a high risk of intraoperative complications. We present a 76-year-old male patient with massive aortic and mitral valve calcification involving the left atrium, the left ventricle and the left ventricular outflow tract. Both valves exhibited severe stenosis and moderate to severe regurgitation. The left ventricle was hypertrophic and the left ventricular ejection fraction was > 55%. The patient was prediagnosed with persistent atrial fibrillation. The risk of death following heart surgery (EuroSCORE II) was calculated as 9.21%. We successfully performed a so-called "UFO procedure" including replacement of both valves without annular decalcification to avoid atrioventricular dehiscence. We enlarged the IVFB and replaced the non-coronary sinus of Valsalva with doubled bovine pericardium. The left ventricular outflow tract was decalcified. The patient was transferred to a local hospital on the 13th postoperative day.

CONCLUSION

Successful surgical treatment to this extent was demonstrated for the first time. Due to the high perioperative mortality, the surgical treatment of patients with this constellation would be refused in most cases. In our patient, the preoperative imaging showed extreme calcification of both valves and the surrounding myocardium. Excellent preoperative planning and a highly experienced surgical team is necessary.