Related Experiment Video
Updated: Aug 18, 2025
Fully Endoscopic Mitral Valve Repair with Percutaneous Cannulation of Groin Vessels
Published on: May 26, 2023
Surgical Outcomes After Reconstruction of the Aortomitral Curtain
Markian Bojko1, Korri S Hershenhouse1, Ramsey S Elsayed1
1Department of Surgery, Division of Cardiac Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, California.
Insights
The commando procedure for aortic and mitral valve disease is complex and carries high risks. While operative mortality is significant, survival rates improve for patients who recover from initial hospitalization.
Area of Science:
- Cardiovascular Surgery
- Cardiac Surgery Outcomes
- Valvular Heart Disease
Background:
- The commando procedure addresses complex aortic and mitral valvular disease involving the aortomitral curtain.
- Surgical outcomes for this technically demanding operation are not extensively documented.
Purpose of the Study:
- To evaluate the outcomes of the commando procedure at a single center.
- To identify risk factors associated with mortality in patients undergoing this complex repair.
Main Methods:
- Retrospective review of patients undergoing concomitant aortic and mitral valve replacement from 2004-2021.
- Analysis of 41 patients who underwent aortomitral curtain reconstruction, utilizing survival analysis and multivariable modeling.
Main Results:
- The study included 41 patients with a median age of 52; common indications included endocarditis (61.0%).
- Operative mortality was high at 34.1%, with previous sternotomy and female gender identified as mortality risk factors.
- 1-year, 3-year, and 5-year survival rates were 55.4%, 50.3%, and 37.7%, respectively.
Conclusions:
- Patients requiring aortomitral curtain reconstruction represent a high-risk cohort with complex indications.
- The commando procedure is associated with substantial perioperative morbidity and mortality, warranting its use only when essential.
- Despite initial risks, favorable outcomes are observed for survivors of the acute surgical phase.
Abstract:
Repair of concomitant aortic and mitral valvular disease with involvement of the aortomitral curtain requires a technically complex operation colloquially termed the commando procedure. Surgical outcomes of this procedure are not well described. The objective of this study was to examine outcomes of the commando procedure at our center. We identified all patients undergoing concomitant aortic and mitral valve replacements from 2004-2021. Of 363 patients, 41 underwent reconstruction of the aortomitral curtain. Survival analysis and multivariable modeling were used to examine outcomes and risk factors for mortality. The median age was 52 (IQR 44-71) years. Preoperatively, 4 of 41 (9.8%) patients had renal failure, and 10 of 41 (24.4%) had a stroke. The most common surgical indication was endocarditis in 25 of 41 (61.0%) patients. 25 of 41 (61.0%) patients underwent redo sternotomy, and 23 of 41 (56.1%) had previous prosthetic valves. Operative mortality was 14 of 41 (34.1%), and 8 of 41 (9.5%) patients received a permanent pacemaker. Survival at 1, 3, and 5 years was 55.4% (95% confidence interval (CI), 40.6-75.5%), 50.3% (35.0-72.3%), and 37.7% (19.3-73.9%) respectively. Cox proportional hazards regression identified previous sternotomy (HR 4.76, 95% CI 1.21-18.73), and female gender (HR 1.39, 95% CI 1.17-13.82) as risk factors for mortality. Patients undergoing reconstruction of the aortomitral curtain represent a high-risk population with complex surgical indications. Due to high perioperative morbidity and mortality, this procedure should be performed only when necessary. Despite a high up front morbidity burden, outcomes remain favorable for patients who survive the initial hospitalization.
