Contemporary experience with the Commando procedure for anterior mitral anular calcification

Mona Kakavand; Filip Stembal; Lin Chen; Rashed Mahboubi; Habib Layoun; Serge C Harb; Fei Xiang; Haytham Elgharably; Edward G Soltesz; Faisal G Bakaeen; Kevin Hodges; Patrick R Vargo; Jeevanantham Rajeswaran; Austin Firth; Eugene H Blackstone; Marc Gillinov; Eric E Roselli; Lars G Svensson; Gösta B Pettersson; Shinya Unai; Marijan Koprivanac; Douglas R Johnston

doi:10.1016/j.xjon.2023.10.038

Contemporary experience with the Commando procedure for anterior mitral anular calcification

JTCVS Open. 2023 Nov 30:18:12-30. doi: 10.1016/j.xjon.2023.10.038. eCollection 2024 Apr.

Authors

Mona Kakavand¹, Filip Stembal¹, Lin Chen², Rashed Mahboubi¹, Habib Layoun³, Serge C Harb³, Fei Xiang¹, Haytham Elgharably¹, Edward G Soltesz¹, Faisal G Bakaeen¹, Kevin Hodges¹, Patrick R Vargo¹, Jeevanantham Rajeswaran⁴, Austin Firth⁴, Eugene H Blackstone^{1

4}, Marc Gillinov¹, Eric E Roselli¹, Lars G Svensson¹, Gösta B Pettersson¹, Shinya Unai¹, Marijan Koprivanac¹, Douglas R Johnston¹

Affiliations

¹ Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
² Case Western Reserve University School of Medicine, Cleveland, Ohio.
³ Department of Cardiovascular Medicine, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
⁴ Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio.

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.