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Commando Procedure in a Patient With Aortic and Mitral Valve Prostheses: Fourth Intervention for Bacterial Endocarditis

Tuesday, June 18, 2024

Mangino D, Magagna P, Cisico S. Commando Procedure in a Patient With Aortic and Mitral Valve Prostheses: Fourth Intervention for Bacterial Endocarditis. June 2024. doi:10.25373/ctsnet.26058088

The patient is a thirty-year-old woman who underwent an aortic valve replacement in 2021, aortic prosthesis and mitral valve replacement in 2022 for endocarditis, and a redo operation for dysfunction/dehiscence of the mitral valve in February 2023. She was affected by systemic lupus erythematosus and suffered from chronic renal insufficiency requiring dialysis waiting renal transplantation. 

The patient presented in December 2023 with a fever and positive blood cultures. An echocardiography revealed dislodgement of the mechanical aortic prosthesis, severe regurgitant jet adjacent to the prosthetic valve, presence of valvular vegetations, and signs of heart failure.

Surgeons began the procedure with right femoral artery and vein cannulation followed by resternotomy and lysis of mediastinal adhesions. Next, cannulation of the superior vena cava and venous sinus for retrograde cardioplegia and circling superior and inferior vena cava were completed.

Cardiopulmonary bypass (CPB) and aortic cross clamping began, along with administration of retrograde del Nido cardioplegia. An aortotomy and removal of the aortic mechanical prosthesis were completed without any difficulty.

After, finding of the severely destroyed area of the Aortic annulus between the left and right sinuses, surgeons continued with debridement of the annulus and removal of the infected tissue. Vertical extension of aortotomy was executed to the noncoronary aortic sinus and annulus and to the dome of the left atrium. The right atrial wall and left atrial roof were opened to allow access to the mitral valve and the mechanical mitral prosthesis was removed. The aortic annulus was reconstructed with a bovine pericardial patch using 4.0 polypropylene continuous sutures.

The next step was placement of U-stitches in Ethibond 2.0 with pledgets in the posterior mitral annulus, followed by implantation of a 29 mm mitral bioprosthesis. The anterior portion of the mitral annulus between the anterior and posterior trigones was reconstructed by suturing the base of a bovine pericardial patch to the sewing cuff of the mitral prosthesis.

The left atrium roof was then closed using 4.0 polypropylene continuous sutures. The new aortic annulus diameter was measured using dedicated valve sizers. After aortic wall reconstruction, the bioprosthesis was implanted using U-stitches in Ethibond 2.0 with pledgets.

Aortic wall reconstruction was then completed and the bioprosthesis was implanted. The aortotomy and the right atrium were closed using 4.0 polypropylene continuous sutures. Finally, surgeons completed a deairing maneuver and released the aortic clamp. Intraoperative transesophageal echocardiography (TEE) demonstrated good functioning of the bioprosthesis.


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Very nice video of a complex procedure. I find it easier to pre-attach a folded pericardial patch on the mitral prosthesis prior to implantation of the prosthesis itself and use one part of the patch as the neo-atrial septum and the other one as the neo-aorta. I do, however, disagree with the use of a mitral bioprosthesis on a 30 year old ESRD patient on dialysis. You may have to be back in five years (5th time in) and will have to redo the entire commando because the pericardial patch will be calcified and not hold valve sutures. Been there, with a very high mortality. Having said that, this is a great video on a very rough procedure and you deserve congratulations for your successful effort.

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