Reconstruction of the Left Trigone During the Commando Procedure for Invasive Prosthetic Aortic Valve Endocarditis

A 44-year-old male with past medical history of mechanical aortic valve replacement presented with methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia secondary to a dialysis fistula infection. He developed complete heart block, which required temporary transvenous pacing wires placement. During surgery, the prosthetic aortic valve was explanted, and a large abscess cavity was observed underneath the left coronary sinus, extending to the dome of the left atrium and destroying the anterior mitral leaflet. The abscess cavity was debrided, revealing that the left fibrous trigone was destroyed along with the aorto-mitral curtain. The authors decided to proceed with the Commando procedure due to the extent of infective endocarditis (IE) in the fibrous skeleton of the heart and mitral valve. The mitral valve was replaced with a biological prosthesis. Due to the large tissue defect and the destruction of the left trigone down to the level of the mitral prosthesis strut, a decision was made to reconstruct the left trigone with a separate triangular patch before placing the homograft to avoid interference with aortic valve function or left ventricular outflow tract (LVOT) obstruction. A pericardial patch was used to close the dome of the left atrium. The #26 homograft was trimmed and implanted into the LVOT, including the reconstructed left trigone patch and the dome of the left atrium patch. The procedure concluded without complications. A postoperative echocardiogram showed a well-functioning aortic homograft and mitral prosthesis without leak. The patient was discharged to a rehabilitation facility after five weeks to continue recovery. 

References

1. Simplified Running Suture Technique for Allograft Implantation in Cases of Aortic Root Abscess. Michael Javorski, MD and Haytham Elgharably, MD, PhD, FACS. https://www.ctsnet.org/article/simplified-running-suture-technique-allograft-implantation-cases-aortic-root-abscess
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