Reconstruction of the Aorto-Mitral Curtain in Complex Infective Endocarditis: A Contemporary Narrative Review of the...

Infective endocarditis (IE) remains a life-threatening condition, particularly in complex cases with destruction of the aorto-mitral curtain (AMC), also known as the intervalvular fibrous body (IVFB). Multiple factors have contributed to an increased incidence of IE and more extensive destruction of the valvular apparatus, necessitating more aggressive surgical intervention. Thus, this study aimed to evaluate the role and outcomes of the Commando procedure in managing IE involving the AMC. A narrative literature review was conducted to provide a comprehensive overview of the Commando procedure in IE involving the AMC, focusing on recent trends, indications, operative strategies, and outcomes. The keywords "infective endocarditis", "Commando procedure", "aorto-mitral curtain", "intervalvular fibrous body", and "double-valve replacement" were searched in PubMed, Web of Science, and Google Scholar. Only English language studies were included. Inclusion criteria comprised studies involving IE patients who underwent the Commando procedure or any associated modified version; studies reporting conventional double-valve replacement (DVR) performed for IE without AMC involvement were also included for comparison. Exclusion criteria included patients who underwent the Commando procedure for non-infection indications, such as small annuli or calcification. Commando surgery was associated with a 30-day mortality of 9-32%, with 1-, 5-, and 10-year survival rates of 55.4-92.9%, 37.7-68%, and 37-48%, respectively. High-risk factors included infection by specific microorganisms and the need for emergency surgery. The Hemi-Commando procedure demonstrated lower early mortality (8-13.6%), higher 1-year survival (77.5-91%), and 92.3% freedom from reoperation at 1-3 years. Compared with DVR, the Commando procedure had higher operative mortality but similar long-term survival after risk adjustment. Despite the associated high perioperative risks, the Commando surgical procedure remains critical for managing complex IE with AMC destruction. Modified techniques may balance infection control and functional preservation, potentially improving survival in selected patients. Future research should focus on standardized surgical protocols, long-term durability, and multidisciplinary collaboration to optimize outcomes.