Double Annular Enlargement as an Effective Technique to Overcome Patient-Prosthesis Mismatch

A 35-year-old woman, who had undergone an aortic valve replacement (AVR) with a 19 mm mechanical prosthesis nine years prior presented with exertional fatigue and shortness of breath despite a well-functioning mechanical prosthesis. Her body mass index (BMI) was 36.2, and she had a significant left ventricular outflow tract gradient that was attributed to patient-prosthesis mismatch. She had a history of rheumatic valvular heart disease, and her echocardiogram showed the mitral valve had a mixed degree of stenosis and regurgitation.

A decision was made to proceed with a reoperation to replace both the aortic and mitral valves using the double annular enlargement (Commando) technique to overcome any potential for patient-prosthesis mismatch. The principle of the technique is to open the inflow and outflow of the left ventricle by combining the extended Manouguian posterior aortic root enlargement with the left atrial dome Meyer’s approach, which creates one common opening for the inflow and outflow of the left ventricle.

This was followed by the placement of the mitral prosthesis—in this case, a 31 mm mechanical prosthesis—and the reconstruction of the aorto-mitral curtain, or the intervalvular fibrosa. Subsequently, the aortic prosthesis (a 25 mm mechanical aortic valve) was placed, followed by the completion of the aortic root patch augmentation and the closure of the aortotomy.

This technique is very effective for avoiding patient-prosthesis mismatch and is based on the experience gained from endocarditis cases, where the intervalvular fibrosa requires reconstruction in extensive root endocarditis cases.

The patient had uneventful recovery, was extubated 24 hours later, and continued to do well during her follow-up with no significant inflow or outflow tract gradients.

References

1. Gamal Marey, Sameh M Said. Combined Manouguian-Guiraudon Approach for Double Valve Replacement: The Commando Revisited. Ann Thorac Surg. 2021 Feb;111(2):e139-e141

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