Re-operative hemi-commando operation without a homograft: an alternative approach for complex aortic root abscess

The patient was in his late 70s with a prior history of aortic valve replacement, recent emergent percutaneous coronary intervention for the right coronary artery (RCA), and a chronic type A aortic dissection and a 6-cm ascending aortic aneurysm. He developed Staphylococcus epidermidis bacteraemia and was found to have an aortic root abscess. Echocardiography demonstrated dehiscence of the aortic bioprosthesis with an aortic root abscess and moderate-to-severe mitral regurgitation. Radical debridement was performed, including resection of the aorto-mitral curtain through an extended transseptal approach. The protruding RCA stent was partially resected to allow selective cardioplegia. Mitral valve repair was performed with implantation of a 30-mm partial annuloplasty ring. A rectangular double-patch technique was used. The first bovine pericardial patch was sewn to the dome of the left atrium, and the second patch reconstructed the aortic annulus, with reinforcement of the fibrous trigones using pledgeted sutures. A handmade composite Bentall graft was constructed using a 30-mm Dacron graft with a skirted 25-mm bioprosthesis, and implanted with non-everting sutures. Both coronary buttons were reimplanted, followed by hemiarch replacement. The right atrium was closed with a separate pericardial patch, and a saphenous vein graft was placed to the distal RCA.