Hemi-Commando Procedure for Bioprosthetic Aortic Valve Endocarditis

A 74-year-old male with hypertension, hyperlipidemia, paroxysmal atrial fibrillation, and a previous transcatheter bioprosthetic aortic valve of less than one year presented to an outside facility with repetitive embolic phenomenon to the lower extremities, requiring open incisions and embolectomy.

The patient was diagnosed with sepsis secondary to transcatheter aortic valve endocarditis, aortic root abscess, and mitral valve abscess. The patient was then transferred to the authors’ facility for medical optimization and for a hemi-commando procedure and aortic root replacement.

Upon median sternotomy, gross purulent fluid was encountered. Once the heart was arrested, the aortic root was opened, and the prosthetic transcatheter aortic valve replacement (TAVR) was inspected. The incision was carried down to the aortic annulus and noncoronary sinus, with gross purulence coming from the left atrium, root, and valve. The aorto-mitral curtain was infected, with extension into the anterior mitral leaflet. Coronary buttons were fashioned, and the left ventricular outflow tract was debrided. An atrial clip was placed on the left atrial appendage.

The infected aortic root, TAVR, native aortic valve, anterior leaflet of the mitral valve, left ventricular outflow tract, and left atrial dome were removed. Bovine pericardium was used to reconstruct portions of the aortic annulus, anterior mitral leaflet, left atrium, and aorto-mitral curtain as a hemi-commando single path. A 23 mm aortic valve conduit was then implanted and anastomosed to the distal ascending aorta. The patient was weaned off cardiopulmonary bypass, and the chest was closed in the usual fashion. Postoperative echocardiography revealed a well-seated aortic valve and root with good function.

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References

1. David TE, Kuo J, Armstrong S. Aortic and mitral valve replacement with reconstruction of the intervalvular fibrous body. J Thorac Cardiovasc Surg 1997;114:766-71; discussion 771-2. 10.1016/S0022-5223(97)70080-1
2. Navia JL, Al-Ruzzeh S, Gordon S, et al. The incorporated aortomitral homograft: a new surgical option for double valve endocarditis. J Thorac Cardiovasc Surg 2010;139:1077-81. 10.1016/j.jtcvs.2009.05.017
3. De Oliveira, N. C., David, T. E., Armstrong, S., & Ivanov, J. (2005). Aortic and mitral valve replacement with reconstruction of the intervalvular fibrous body: an analysis of clinical outcomes. The Journal of Thoracic and Cardiovascular Surgery, 129(2), 286-290

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