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. 2020 Apr;12(4):1427-1436.
doi: 10.21037/jtd.2020.03.04.

Aortic and mitral valve surgery for infective endocarditis with reconstruction of the intervalvular fibrous body: an analysis of clinical outcomes

Xuan Jiang  1 , Jinduo Liu  1 , Fareed Khan  1 , Rui Tang  1 , Yuhai Zhang  1 , Tianxiang Gu  1
Affiliations

Aortic and mitral valve surgery for infective endocarditis with reconstruction of the intervalvular fibrous body: an analysis of clinical outcomes

Xuan Jiang et al. J Thorac Dis. 2020 Apr.

Abstract

Background: Reconstruction of the aorto-mitral curtain (AMC) for invasive double-valve infective endocarditis (IE) is a rare and challenging procedure. This study presents the short- and mid-term results of reconstruction of AMC in a single center.

Methods: From 2016 to 2019, 14 patients with invasive double-valve underwent surgical reconstruction of the AMC, along with either double valve replacement or aortic valve replacement with mitral valve repair. Two patients were diagnosed as Behcet's disease. Bicuspid aortic valve was detected in six patients. Mean follow up was 18.9±12.2 months.

Results: Positive blood culture was found in 10 (71.4%) patients: 3 of Abiotrophia defective (21.4%). The mean cardiopulmonary bypass (CPB) time was 154.5±25.9 minutes and the mean cross-clamp time was 116.8±18.2 minutes. One patient died of multiple organ failure (7.1%) 60 days after surgery. There was 1 (7.1%) case of stroke, 1 (7.1%) of atrioventricular block with pacemaker implantation, 1 (7.1%) of reoperation for bleeding. There was no late death during follow-up. The survival at 3 years was 92.9%. Freedom from reoperation at 1, 2, and 3 years was 100%, 100%, and 100% during follow-up, respectively.

Conclusions: The double-valve replacement and AMC reconstruction (the Commando procedure) is an effective technique in complex heart valve disease. The short- and mid-term results with this technique are optimal, with a very low in-hospital mortality and nearly 100% of long-term survival during follow-up.

Keywords: Commando procedure; Infective endocarditis (IE); aorto-mitral curtain (AMC); patch repair.

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Conflict of interest statement

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/jtd.2020.03.04). The authors have no conflicts of interest to declare.

Figures

Figure 1
Figure 1
Part A of surgical technique for the Commando procedure. (A) Debridement of the infected valve and aortic root; (B) inspection of the left atrium (LA), the left ventricular outflow tract (LVOT) and the posterior mitral valve (MV); (C) mitral valve replacement; (D,E) to suture the pericardial patch to the artificial MV; (F) reconstruction of the aortic-mitral curtain (AMC) with a pericardial patch.
Figure 2
Figure 2
Part B of surgical technique for the Commando procedure. (A,B) Closure of left atrium roof; (C) reconstruction of aortic root with the inner layer of patch; (D,E) Bentall procedure; (F) anastomosis of the coronary sinus ostium.
Figure 3
Figure 3
Schematic diagram of the Commando procedure. (A,B) Debridement of the infection; (C) mitral valve replacement; (D) reconstruction of AMC; (E) closure of left atrium roof; (F) reconstruction of aortic root. MV, mitral valve; LCA, left coronary artery; RCA, right coronary artery; LA, left atrium; AMC, aortic-mitral curtain.
Figure 4
Figure 4
Echocardiogram of double-valve endocarditis. (A) Blue arrow, paravalvular abscesses. (B) Red arrow, aortic valve vegetation. (C) Green arrow, infected thickened aortic-mitral curtain. (D) Red arrow, mitral valve vegetation. (E,F) Red arrow, vegetation of AMC. Ao, aorta; LA, left atrium; RA, right atrium; RVOT, right ventricular outflow tract; LV, left ventricle; AMC, aorto-mitral curtain.
Figure 5
Figure 5
Infective endocarditis with AMC vegetation. (A) Bicuspid aortic valve with vegetation; (B) infected AMC; (C) infected vegetation of AMC and anterior mitral valve; (D) resection of part of AMC. Green arrow, vegetations. AMC, aorto-mitral curtain.
See this image and copyright information in PMC

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