Commando Procedure: the advantage of the transseptal approach in reintervention

The technical challenge of the Commando procedure in a reintervention context

The Commando procedure, involving simultaneous replacement of the aortic and mitral valves combined with reconstruction of the mitro-aortic fibrous body, represents one of the most arduous challenges in cardiac surgery. Usually performed via an aortotomy extended towards the roof of the left atrium, this intervention becomes particularly perilous in cases of multiple reinterventions, where dense adhesions and anatomical remodeling limit exposure and increase the risk of injury.

The objective of this study is to demonstrate the benefits of the combined superior transseptal approach as a strategic alternative to optimize the surgical field. By facilitating access to the floor of the left atrium and the fibrous skeleton, this technical variant aims to secure dissection and improve the reliability of prosthetic implantation, particularly for the insertion of large-diameter biological valves (25 mm) despite complex anatomical conditions.

The hypothesis evaluated is based on the ability of this surgical approach to standardize pericardial patch reconstruction maneuvers, ensuring better surgical precision while minimizing the need for extensive dissection of surrounding structures. The clinical challenge is to improve the reproducibility of a procedure with high operative mortality, particularly in patients with a history of coronary artery bypass grafting and valvular repair.

Design and surgical protocol

This case report (N=1) details the execution of a complex Commando procedure via a superior transseptal approach. The intervention was performed by median resternotomy under general anesthesia. The protocol began with a left internal thoracic artery (LITA) bypass to the former saphenous vein graft (SVG) using 7-0 polypropylene sutures under ECMO support.

The surgical technique followed a standardized sequence:

• Support et protection : Établissement d'une circulation extracorporelle (CEC) via perfusion aortique ascendante et drainage bi-cave. La protection myocardique a été assurée par cardioplégie rétrograde dans le sinus coronaire après clampage aortique.
• Combined approach: An oblique aortotomy was connected to a superior transseptal incision extending to the roof of the left atrium. Following the failure to pass a 21 mm sizer through the aortic annulus, the decision to proceed with enlargement via the Commando technique was confirmed.
• Resection and Reconstruction: The aortotomy was extended between the left and non-coronary commissures, crossing the aortic and mitral annulus after explantation of a 26 mm Memo 4D ring. An oval-shaped bovine pericardial patch (width calibrated at +1 cm relative to the inter-trigonal distance) was used to reconstruct the intervalvular fibrous body (IVF).
• Valve implantations: Placement of a 25 mm MITRIS bioprosthesis in the mitral position (interrupted sutures with pledgets on two-thirds of the circumference) and a 25 mm INSPIRIS valve in the aortic position.
• Associated procedures: Tricuspid annuloplasty (MC3 ring) and closure of the right atrium with a patch.

L'analyse des résultats a été effectuée par échocardiographie per et postopératoire et par angiographie CT pour valider la fonctionnalité valvulaire, la morphologie de la zone reconstruite et la perméabilité du greffon.

Results: Technical success and rapid hemodynamic recovery

The procedure allowed for overcoming the major anatomical constraints identified intraoperatively. Initially, after decalcification of the aortic valve, the passage of a 21 mm sizer proved impossible, confirming the necessity of annular enlargement via the Commando procedure.

Technical success was validated by the implantation of two large-diameter bioprostheses, optimizing the patient's hemodynamic profile despite her small body surface area (BSA 1.43 m²). The devices and techniques used include:

• Mitral position: Implantation of a 25 mm MITRIS valve (fixed on two-thirds of the native circumference).
• Aortic position: Implantation of a 25 mm INSPIRIS valve.
• Reconstruction: Use of an oval-shaped bovine pericardial patch for the intervalvular fibrous body (IVF), the roof of the left atrium and the interatrial septum.
• Associated procedure: Tricuspid annuloplasty with an MC3 ring.

Postoperative follow-up and imaging

Clinical recovery was marked by rapid weaning from circulatory support, despite the initial septic and cardiogenic shock. The recovery milestones are detailed in the following table:

Postoperative echocardiography confirmed the proper functioning of both prosthetic valves, with a total absence of paravalvular leakage. The follow-up computed tomography (CT) scan showed the patency of the aortocoronary bypass grafts (LITA on SVG) and a satisfactory morphology of the area reconstructed by the pericardial patch. No major complications were reported during the hospital phase.

The transseptal approach: a major exposure lever

In this complex case, the use of the superior transseptal approach transformed a technically perilous Commando procedure into a systematized intervention. Faced with the dense adhesions of a reoperation, this approach provided a stable operative field, facilitating the reconstruction of the mitro-aortic fibrous body without extensive dissection of the surrounding structures. For the surgeon, this increased visibility is decisive in ensuring the precision of the sutures on a remodeled annulus.

The strategic choice of bioprostheses responded here to a clinical safety imperative: minimizing the postoperative hemorrhagic risk in a patient on steroids and with end-stage renal failure. Avoiding a mechanical valve made it possible to bypass the constraints of heavy anticoagulation in a context of initial septic and cardiogenic shock. The success of ECMO weaning on the very day of the procedure and discharge at D14 validate the viability of this aggressive but controlled surgical strategy.

However, this case report remains limited by its unique nature and restricted clinical follow-up. While the morphology of the reconstructed area is satisfactory on the postoperative CT scan and the prostheses are functional, the durability of this complex assembly in a dialysis patient requires rigorous monitoring. Nevertheless, this technique stands out as a robust alternative to classic left atrial roof incisions, which are often insufficient during reoperations with major adhesions.

Summary of results

This clinical case illustrates the success of a complex Commando procedure performed via a superior transseptal approach in a multi-operated patient. This surgical strategy allowed for the implantation of two 25 mm bioprostheses (MITRIS in the mitral position and INSPIRIS in the aortic position) as well as the reconstruction of the intervalvular fibrous body using a bovine pericardium patch. The postoperative course was favorable, marked by extubation at D5 and patient discharge at D14, confirming the stability of the reconstruction and the optimal functionality of the implanted valves.

In concrete terms, for the practitioner:

• Favor the superior transseptal approach for reinterventions: this route offers optimal exposure of the left atrial roof and the fibrous framework, limiting risky dissections in areas of strong cicatricial adhesions.
• Secure prosthesis anchoring: the use of a bovine pericardium patch allows for the recreation of a stable suture base, facilitating the implantation of large diameter valves (25 mm) even in degraded anatomical environments.
• Standardise complex maneuvers: the clarity of the surgical field provided by this technique allows for precise and reproducible execution of the Commando procedure, thus securing a technically highly demanding intervention.

Technical Lexicon of the Clinical Case

Commando Procedure: An extremely complex surgical intervention consisting of a double valve replacement (aortic and mitral) associated with a reconstruction of the heart's structural integrity, necessitated in this patient by massive calcifications.

Intervalvular fibrous body (IVF): Anatomical structure ensuring continuity between the aortic and mitral rings. Its complete reconstruction via a bovine pericardial patch allowed for the stabilization of both prostheses (INSPIRIS and MITRIS) in this reintervention case.

Superior transseptal approach: Surgical approach combining an aortotomy and an incision of the roof of the left atrium through the interatrial septum. This technique offered superior exposure of the operative field, crucial for bypassing the patient's anatomical obstacles.

ECMO (Extracorporeal Membrane Oxygenation): Circulatory life support implemented during the acute phase to stabilize the patient while she was in cardiogenic and septic shock prior to the intervention.

IABP (Intra-aortic balloon pump): Temporary mechanical assistance used to support failing cardiac function preoperatively, for which weaning could be achieved from the first postoperative day (D1).

Pericardial adhesions: Dense scar tissue resulting from the patient's previous bypass and mitral repair surgeries. Their massive presence dictated the choice of the transseptal approach to reduce the risk of intraoperative tissue damage.

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