The Commando Revisited in Adolescent with Severe Aortic and Mitral Valve Stenosis

The patient, now a fifteen-year-old boy, was born with multivalvular disease with congenitally stenotic bicuspid aortic valve (AV). This was combined with congenital mitral valve (MV) stenosis and Ebsteinoid regurgitant tricuspid valve (TV). He underwent two previous sternotomies for repair and re-repair of all three valves. He also had a previous supravalvular aortic stenosis that was relieved by patch aortoplasty.

He presented with symptomatic exertional palpitations, dizziness, and presyncope. Preoperative studies showed combined mixed MV stenosis and regurgitation. A dobutamine stress echocardiogram showed severe left ventricular outflow tract obstruction secondary to recurrent severe aortic stenosis.

The decision was made to proceed with a third sternotomy and replacement of both AV and MV. because of the small annuli, a double annular enlargement (DAE) technique was used. The procedure was performed via a third sternotomy with aortic and bicaval cannulation. Antegrade cardioplegia was utilized.

Combining extended Manouguian and Guiraudon—extended superior trans-septal—incisions resulted in widely opened inflow and outflow tracts of the left ventricle. The aortic valve cusps and MV anterior and most of the posterior leaflets were resected.

A 29 mm St. Jude mechanical mitral prosthesis was then secured along the posterior mitral annulus with multiple interrupted pledgeted 2-0 Ethibond sutures, with the pledgets on the ventricular side. A folded bovine pericardial patch was used to reconstruct the aortomitral curtain and was secured to the anterior mitral prosthesis sewing ring using running 4-0 Prolene suture. The lower half of the patch was then used to reconstruct the left atrial dome and interatrial septum. The upper half of the patch was used to reconstruct the aortic wall and later to close the aortotomy.

The aortic prosthesis, a 25 mm Carbo-Medics Top Hat, was then secured to the aortic annulus using multiple interrupted pledgeted 2-0 Ethibond sutures, with the pledgets on the ventricular side. In the area of the pericardial patch, the sutures were placed from the outside in. The aortotomy was then closed using the bovine pericardial patch and running 4-0 Prolene suture. Next, the upper portion of the right atrium and superior vena caval/right atrial junction was reconstructed using a small bovine pericardial patch. The remainder of the right atriotomy was then closed with running 4-0 Prolene suture followed by removal of the caval snares.

The heart was de-aired, and the aortic cross clamp was removed. The patient regained his normal sinus rhythm and was ventilated and weaned off cardiopulmonary bypass without difficulty. Post-bypass transesophageal echocardiogram showed both well-functioning aortic and mitral prostheses with single digit gradient across the inflow and outflow tracts of the left ventricle. Ventricular function was preserved.

The left ventricular outflow tract gradient was measured directly and confirmed the absence of any significant gradient. The patient was then decannulated and protamine was administered, followed by chest closure in the standard fashion.

The postoperative course was uneventful. The patient was extubated in the operating room and received no transfusions. He was discharged on Warfarin anticoagulation and Aspirin seven days after his surgery.

The predischarge echocardiogram and CT scan showed good biventricular functions and normally functioning aortic and mitral prostheses. He continued to do well during his follow-up.

References

1. Manouguian S, Seybohl-Epting W. Patch enlargement of the aortic valve ring by extending the aortic incision into the anterior mitral leaflet. New operative technique. J Thorac Cardiovasc Surg. 1979; 78: 402-412
2. Guiraudon GM, Ofiesh JG, Kaushik R. Extended vertical transatrial septal approach to the mitral valve. Ann Thorac Surg. 1991; 52 ([discussion: 1060-1062]): 1058-1060
3. David TE, Kuo J, Armstrong S. Aortic and mitral valve replacement with reconstruction of the intervalvular fibrous body. J Thorac Cardiovasc Surg. 1997; 114: 766-772
4. Said SM, Mare GM. Combined Manouguian and Guiraudon approach for double valve replacement: The commando revisited. Ann Thorac Surg 2021; 111(2): e139-e141

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