This presentation details a redo Commando procedure converting biological to mechanical valves in a patient in his early 40s with end-stage renal disease. Three years after his initial Commando procedure with aortic and mitral bioprostheses, he developed severe prosthetic valve dysfunction with extensive calcification, presenting with heart failure symptoms. Preoperative imaging showed mean gradients of 34 mmHg across the aortic valve and 24 mmHg across the mitral valves, along with severe tricuspid regurgitation and postcapillary pulmonary hypertension. Given the rapid valve degeneration and calcium metabolic disorder from chronic kidney disease, mechanical valve replacement was planned. 

The surgical approach involved redo sternotomy with lysis of dense adhesions, explantation of both biological valves while preserving annular integrity, and complete takedown of the previous aorto-mitral curtain reconstruction with meticulous debridement of the trigonal corners. Mechanical mitral and aortic valves were implanted, carefully sized to avoid tension on suture lines. A diamond-shaped bovine pericardial patch reconstructed the aorto-mitral curtain, with pledgeted corner reinforcement sutures to prevent bleeding and paravalvular leak. Tricuspid valve repair with a 30 mm annuloplasty band was also performed. The cross-clamp time was two hours 56 minutes. The patient was successfully separated from bypass but required brief veno-venous extracorporeal membrane oxygenation (VV-ECMO) for pulmonary dysfunction. Postoperative imaging demonstrated well-functioning mechanical prostheses with proper orientation, normal biventricular function, and no paravalvular leak. 

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