Mona Kakavand MD , Filip Stembal MD , Lin Chen BA , Rashed Mahboubi MD , Habib Layoun MD , Serge C. Harb MD , Fei Xiang MD , Haytham Elgharably MD , Edward G. Soltesz MD , Faisal G. Bakaeen MD , Kevin Hodges MD , Patrick R. Vargo MD , Jeevanantham Rajeswaran PhD , Austin Firth MS , Eugene H. Blackstone MD , Marc Gillinov MD , Eric E. Roselli MD , Lars G. Svensson MD, PhD , Gösta B. Pettersson MD, PhD , Shinya Unai MD , Douglas R. Johnston MD
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We referenced outcomes after Commando procedures to standard double-valve replacements.</p></div><div><h3>Methods</h3><p>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).</p></div><div><h3>Results</h3><p>Between balanced groups, Commando versus double-valve replacement had higher total calcium scores (median 6140 vs 2680 HU, <em>P</em> = .03). Hospital outcomes were similar, including operative mortality (12/11% vs 8/7.3%, <em>P</em> = .35) and reoperation for bleeding (9/8.3% vs 5/4.6%, <em>P</em> = .28). Survival and freedom from reoperation at 5 years were 54% versus 67% (<em>P</em> = .33) and 87% versus 100% (<em>P</em> = .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, <em>P</em> = .04). After Commando procedures for calcification, 5-year survival was 60% and 59% with and without radiation, respectively (<em>P</em> = .47).</p></div><div><h3>Conclusions</h3><p>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.</p></div>","PeriodicalId":74032,"journal":{"name":"JTCVS open","volume":null,"pages":null},"PeriodicalIF":0.0000,"publicationDate":"2024-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S2666273623003698/pdfft?md5=44a615e4dd813ed1d87a45b7bec54611&pid=1-s2.0-S2666273623003698-main.pdf","citationCount":"0","resultStr":"{\"title\":\"Contemporary experience with the Commando procedure for anterior mitral anular calcification\",\"authors\":\"Mona Kakavand MD , Filip Stembal MD , Lin Chen BA , Rashed Mahboubi MD , Habib Layoun MD , Serge C. Harb MD , Fei Xiang MD , Haytham Elgharably MD , Edward G. Soltesz MD , Faisal G. Bakaeen MD , Kevin Hodges MD , Patrick R. Vargo MD , Jeevanantham Rajeswaran PhD , Austin Firth MS , Eugene H. 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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).</p></div><div><h3>Results</h3><p>Between balanced groups, Commando versus double-valve replacement had higher total calcium scores (median 6140 vs 2680 HU, <em>P</em> = .03). Hospital outcomes were similar, including operative mortality (12/11% vs 8/7.3%, <em>P</em> = .35) and reoperation for bleeding (9/8.3% vs 5/4.6%, <em>P</em> = .28). Survival and freedom from reoperation at 5 years were 54% versus 67% (<em>P</em> = .33) and 87% versus 100% (<em>P</em> = .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, <em>P</em> = .04). After Commando procedures for calcification, 5-year survival was 60% and 59% with and without radiation, respectively (<em>P</em> = .47).</p></div><div><h3>Conclusions</h3><p>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. 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引用次数: 0
摘要
目的二尖瓣前瓣膜钙化,尤其是放射性心脏病患者,以及既往瓣膜置换术中瓣间纤维被破坏,都对假体的尺寸和置放提出了挑战。通过重建瓣间纤维的Commando手术可以在这些困难情况下进行双瓣膜置换。方法从 2011 年 1 月到 2022 年 1 月,克利夫兰诊所共进行了 129 例 Commando 手术和 1191 例主动脉和二尖瓣双瓣膜置换术,其中不包括心内膜炎。进行Commando手术的原因包括放射治疗后严重钙化(67例)、无放射治疗(43例)和其他(19例)。结果在平衡组之间,Commando手术与双瓣膜置换术相比,钙化总分更高(中位数6140 HU vs 2680 HU,P = .03)。住院结果相似,包括手术死亡率(12/11% vs 8/7.3%,P = .35)和因出血再次手术率(9/8.3% vs 5/4.6%,P = .28)。5年的存活率和免再手术率分别为54%对67%(P = .33)和87%对100%(P = .04)。钙化评分越高,双瓣膜置换术后的存活率越低,但Commando术后则不然。Commando手术4年后的主动脉瓣平均梯度较低(9.4 vs 11 mm Hg,P = .04)。结论Commando手术重建了被二尖瓣瓣口钙化、辐射或既往手术破坏的瓣间纤维,其结果与标准双瓣置换术相似,可以接受。需要更多的经验和长期疗效来完善Commando方法的患者选择和应用。
Contemporary experience with the Commando procedure for anterior mitral anular calcification
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.