Modified Re-Do Commando Procedure in a Patient With Septic Shock Due to Aortic and Mitral Valve Endocarditis

The patient, a 49-year-old female, had undergone aortic root replacement and mitral valve repair due to endocarditis in 2022. In 2023, she required percutaneous transluminal coronary angioplasty (PTCA) and implantation of a drug-eluting stent (DES) due to acute right interventricular artery (RIVA) occlusion. One month later, she presented with another episode of endocarditis affecting the aortic valve prosthesis. The mitral valve repair showed moderate insufficiency caused by dilatation of the left ventricle and tenting after the RIVA occlusion. The tricuspid valve was severely insufficient without signs of infection. A modified Commando procedure was performed, which included aortic root replacement, mitral valve replacement, and tricuspid valve repair on a beating heart. 

The patient then presented with a third episode of endocarditis, characterized by vegetations on the aortic Freestyle prosthesis and the mitral valve replacement. Staphylococcus aureus was isolated in blood cultures. The patient needed high-dose catecholamine support due to septic shock, with a left ejection fraction of (LVEF) 20 percent. The tricuspid valve showed good function after repair. Another modified Commando procedure was planned as ultima ratio. 

Following median resternotomy and dissection of adhesions, a standard cannulation of the ascending aorta and bicaval venous cannulation was performed. Upon opening the aorta, pronounced vegetations on the Freestyle prosthesis became visible. In the previous surgery, access had been gained through the interatrial septum and the dome of the left atrium. After excising old patch material used to reconstruct the right atrium, the interatrial septum was reopened. The coronary ostia were detached from the Freestyle prosthesis. The pulmonary artery was injured due to tight adhesions during the preparation of the left coronary ostia and was later repaired with a separate patch. The Freestyle prosthesis could then be explanted, showing heavy infection. The remaining patch material used to reconstruct the dome of the left atrium and the left ventricular outflow tract (LVOT) was removed, providing access to the mitral valve prosthesis, which also showed massive vegetations.  

Following thorough disinfection, the sutures for the new mitral valve were placed in the posterior part of the mitral annulus. The tricuspid valve function was tested and showed good function without signs of endocarditis. The new mitral valve prosthesis was fixed in the native annulus at about two-thirds of the circumference. A new bovine pericardial patch was measured, trimmed, halved, and fixed to the remaining prosthetic ring. The two halves of the patch were sewn with a continuous 4-0 Prolene suture to reconstruct the dome of the left atrium and the LVOT, enabling the anchoring of the Freestyle prosthesis. 

The interatrial septum was closed directly. After trimming the patch, the left atrial roof was closed. Sutures to anchor the Freestyle prosthesis were placed. Fixation around the ventricular septum was challenging due to infected and unstable tissue, necessitating further resection and placement of deep stitches. The coronary ostia were reimplanted, and free access was verified. The prosthesis and ascending aorta were anastomosed. The right atrium was reconstructed using a pericardial patch in the apical area, and the remaining atriotomy was closed directly. Following reperfusion, a stable intrinsic rhythm was established. 

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