Contemporary experience with the Commando procedure for anterior mitral anular calcification

Abstract

Objective: Anterior mitral anular calcification, particularly in radiation heart disease, and previous valve replacement with destroyed intervalvular fibrosa are challenging for prosthesis sizing and placement. The Commando procedure with intervalvular fibrosa reconstruction permits double-valve replacement in these challenging conditions. We referenced outcomes after Commando procedures to standard double-valve replacements.

Methods: From January 2011 to January 2022, 129 Commando procedures and 1191 aortic and mitral double-valve replacements were performed at the Cleveland Clinic, excluding endocarditis. Reasons for the Commando were severe calcification after radiation (n = 67), without radiation (n = 43), and others (n = 19). Commando procedures were referenced to a subset of double-valve replacements using balancing-score methods (109 pairs).

Results: Between balanced groups, Commando versus double-valve replacement had higher total calcium scores (median 6140 vs 2680 HU, P = .03). Hospital outcomes were similar, including operative mortality (12/11% vs 8/7.3%, P = .35) and reoperation for bleeding (9/8.3% vs 5/4.6%, P = .28). Survival and freedom from reoperation at 5 years were 54% versus 67% (P = .33) and 87% versus 100% (P = .04), respectively. Higher calcium score was associated with lower survival after double-valve replacement but not after the Commando. The Commando procedure had lower aortic valve mean gradients at 4 years (9.4 vs 11 mm Hg, P = .04). After Commando procedures for calcification, 5-year survival was 60% and 59% with and without radiation, respectively (P = .47).

Conclusions: The Commando procedure with reconstruction of the intervalvular fibrosa destroyed by mitral anular calcification, radiation, or previous surgery demonstrates acceptable outcomes similar to standard double-valve replacement. More experience and long-term outcomes are required to refine patient selection for and application of the Commando approach.

Keywords: double-valve replacement; intervalvular fibrosa reconstruction; radiation-associated cardiac disease.

Survival after the Commando procedure and DVR surgery in balanced cohorts.

Figure 1

Longitudinal echocardiographic outcomes after Commando procedure. Solid lines are parametric estimates enclosed within dashed 68% confidence bands (equivalent to 1 standard error). Symbols represent grouped data without regard to repeated measurements to provide crude verification of model fit. Follow-up data for patients and echocardiograms are shown in table: left-hand numbers = patients remaining across follow-up years; right-hand numbers = follow-up echocardiograms available within each yearly interval. A, Postoperative prevalence of each aortic regurgitation grade. B, Postoperative prevalence of each mitral regurgitation grade. C, Temporal trend of postoperative aortic valve mean gradient. D, Temporal trend of postoperative mitral valve mean gradient. E, Temporal trend of postoperative ejection fraction. AV, Aortic valve; MV, mitral valve; LV, left ventricular.

Figure 2

Longitudinal echocardiographic outcomes after Commando procedure and standard DVR in matched cohorts. Solid lines are parametric estimates enclosed within dashed 68% confidence bands (equivalent to 1 standard error). Symbols represent grouped data without regard to repeated measurements to provide crude verification of model fit. Follow-up data for patients and echocardiograms are shown in table: left-hand numbers = patients remaining across follow-up years; right-hand numbers = follow-up echocardiograms available within each yearly interval. A, Postoperative prevalence of moderate or severe aortic regurgitation. B, Postoperative prevalence of moderate or severe mitral regurgitation. C, Temporal trend of postoperative aortic valve mean gradient. D, Temporal trend of postoperative mitral valve mean gradient. E, Temporal trend of postoperative ejection fraction. AV, Aortic valve; DVR, double-valve replacement; MV, mitral valve; LV, left ventricular.

Figure 3

Time-related outcomes after Commando procedure. Solid lines represent parametric estimates enclosed within dashed 68% confidence bands equivalent to 1 standard error. Each symbol represents a Kaplan–Meier estimate of the event, and vertical bars are 68% confidence limits. Numbers below horizontal axes represent patients remaining at risk. A, Aortic valve or mitral valve reoperation. B, Survival.

Figure 4

Time-related outcomes after Commando procedure and standard DVR in matched cohorts. Each symbol represents a Kaplan–Meier estimate of the event, and vertical bars are 68% confidence limits equivalent to ±1 standard error. Numbers below horizontal axis represent patients remaining at risk. A, Aortic valve or mitral valve reoperation. B, Survival. Solid lines are parametric estimates enclosed within dashed 68% confidence bands (equivalent to 1 standard error). DVR, Double-valve replacement.

Figure E1

CONSORT-style diagram of patients undergoing simultaneous aortic and mitral valve replacement with or without a Commando procedure. TAVR, Transcatheter aortic valve replacement.

Figure E2

Quality of balancing score–based matching for Commando and standard DVR. A, Mirrored histogram of distribution of balancing scores before and after matching. Shaded areas represent matched patients. B, Standardized mean differences of selected variables before and after matching. Vertical dashed lines at −10% and +10% indicate boundaries of describing matching. Red triangles represent standardized mean differences before matching, with positive value indicating variables more common in the Commando group and negative value indicating variables more common in the DVR group. AV, Aortic valve; LV, left ventricular; MV, mitral valve; LVEDVi, left ventricular end-diastolic volume index; DVR, double-valve replacement; Std., standardized.

Figure E3

Survival after Commando procedure stratified by reason for surgery. Each symbol represents a death; vertical bars represent 68% confidence limits equivalent to ±1 standard error. Mauve line and circles represent Commando procedures for mitral anular calcification with radiation-associated heart disease. Cyan line and circles represent Commando procedures for mitral anular calcification without radiation-associated heart disease.

Figure E4

Risk-adjusted association between intervalvular fibrosa calcium score and probability of death. Symbols are risk-adjusted predicted 1-month, 6-month, 1-year, and 5-year survival stratified by Commando procedure (red) versus standard DVR (blue) in matched cohorts. Solid lines are smoothed Loess lines of the symbols. DVR, Double-valve replacement.

Figure E5

Risk-adjusted association between aortic valve calcium score and probability of death. Symbols are risk-adjusted predicted 1-month, 6-month, 1-year, and 5-year survival stratified by Commando procedure (red) versus standard DVR (blue) in matched cohorts. Solid lines are smoothed Loess lines of the symbols. DVR, Double-valve replacement; AV, aortic valve.

Figure E6

Risk-adjusted association between mitral valve calcium score and probability of death. Symbols are risk-adjusted predicted 1-month, 6-month, 1-year, and 5-year survival stratified by Commando procedure (red) versus standard DVR (blue) in matched cohorts. Solid lines are smoothed Loess lines of the symbols. DVR, Double-valve replacement; MV, mitral valve.