Surgical Outcomes after Reconstruction of the Aortomitral Curtain: a 17-Year Tertiary Center Experience with the Commando Procedure
Markian Bojko, Korri S. hershenhouse, Ramsey S. Elsayed, Robbin G. Cohen, Vaughn A. Starnes, Michael E. Bowdish
Department of Surgery, Division of Cardiovascular Surgery, University of Southern California Keck School of Medicine, Pasadena, California, United States
Objective
Concomitant aortic and mitral valvular disease with involvement of the aortomitral curtain warrants a technically complex operation colloquially termed the commando procedure. This procedure includes replacement of both aortic and mitral valves with pericardial patch reconstruction of the aortomitral continuity. Surgical outcomes of this procedure are not well described. This study aims to present perioperative and mid-term outcomes in patients undergoing the commando procedure and to identify risk factors influencing post-operative outcomes.
Methods
We queried our institutional STS database for all patients undergoing concomitant aortic and mitral valve replacements from 2004-2021. Of the 363 patients identified, 41 underwent the commando procedure, based on detailed review of operative reports. Standard demographic information and comorbidities were obtained from the STS database. Midterm outcomes were obtained by review of the electronic health record and by telephone calls to all patients. Survival was calculated using the Kaplan Meier method, and risk factors for midterm mortality were analyzed using a cox proportional hazards model.
Results
Among 41 patients who underwent the commando procedure, the median age (IQR) age was 52 (44-71) years. 28/41 (68.3%) patients were male, 4/41 (9.8%) had preoperative renal failure, and 10/41 (24.4%) had a preoperative stroke (Table 1). The most common surgical indication was endocarditis in 25/41 (61.0%) patients. Other indications included annular enlargement of either mitral or aortic valve annuli in 9/41 (22.0%), multiple-time redo surgery with poor tissue quality in 5/41 (12.2%), and severe mitral annular calcification in 2/41 (4.9%). 25/41 (61.0%) patients were undergoing a second time heart surgery, and 11/41 (26.8%) had infected prosthetic valves. Operative mortality in the entire cohort was 14/41 (34.1%), and 8/41 (9.5%) patients received a new postoperative permanent pacemaker. Kaplan-Meier survival (95% CI) at 1, 3, and 5 years was 55.4% (40.6%, 75.5%), 50.3% (35.0%, 72.3%), and 37.7% (19.3%, 73.9%) respectively (Figure 1A). Multivariable cox proportional hazards regression identified redo sternotomy (HR 4.76, 95% CI 1.21 – 18.73), and female gender (HR 1.39, 95% CI 1.17 – 13.82) as significant risk factors for long-term mortality. Patients undergoing redo sternotomy had significantly worse Kaplan-Meier survival compared to patients undergoing first time cardiac surgery (p-value: 0.013, Figure 1B).
Conclusions:
Patients undergoing the commando procedure represent a high-risk population with complex surgical pathologies and indications. Patients undergoing redo heart surgery in this setting may be particularly at risk for postoperative mortality. Despite substantial technical challenges, surgical outcomes remain favorable in centers with significant experience.
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