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A Simplified Stepwise Approach to Echo Guidance during Percutaneous Mitral Valve Repair
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Contemporary experience with the Commando procedure for anterior mitral anular calcification

Mona Kakavand1, Filip Stembal1, Lin Chen2

  • 1Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.

JTCVS Open
|May 1, 2024
PubMed

Insights

The Commando procedure offers acceptable outcomes for complex double-valve replacements, comparable to standard procedures. This technique reconstructs the intervalvular fibrosa, proving effective in challenging cases involving calcification and prior surgery.

Area of Science:

  • Cardiac Surgery
  • Cardiovascular Research
  • Medical Device Technology

Background:

  • Anterior mitral annular calcification and destroyed intervalvular fibrosa present significant challenges in double-valve replacement surgery.
  • Radiation heart disease and prior valve surgery complicate prosthesis sizing and placement.
  • The Commando procedure involves intervalvular fibrosa reconstruction to facilitate complex double-valve replacement.

Purpose of the Study:

  • To evaluate the outcomes of the Commando procedure for double-valve replacement in patients with challenging anatomy.
  • To compare the results of the Commando procedure with standard double-valve replacement techniques.
  • To assess the safety and efficacy of intervalvular fibrosa reconstruction in complex cardiac surgeries.

Main Methods:

  • A retrospective analysis compared 129 Commando procedures with 1191 standard double-valve replacements (DVR) from January 2011 to January 2022.
  • Balancing-score methods were used to create matched pairs (109 pairs) for robust comparison.
  • Outcomes including operative mortality, reoperation, survival, and valve gradients were analyzed.

Main Results:

  • Commando procedures were performed for severe calcification (n=67), often post-radiation, and other complex reasons.
  • Hospital outcomes were similar between Commando and standard DVR groups, including operative mortality and bleeding reoperations.
  • Five-year survival was 54% for Commando vs. 67% for standard DVR (P=.33), with Commando showing lower aortic valve gradients at 4 years (9.4 vs. 11 mm Hg, P=.04).

Conclusions:

  • The Commando procedure demonstrates acceptable outcomes for complex double-valve replacement, comparable to standard DVR.
  • Reconstruction of the intervalvular fibrosa is feasible and effective in challenging calcified or radiation-damaged hearts.
  • Further experience and long-term data are needed to optimize patient selection and application of the Commando approach.
Abstract

Keywords:
double-valve replacementintervalvular fibrosa reconstructionradiation-associated cardiac disease

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