Re-Commando Procedure for Recurrent Endocarditis

A 41-year-old male patient was admitted to the hospital with complaints of shortness of breath at rest, fever, and weakness. His medical history included aortic and mitral valve replacements in 2019 due to infective endocarditis (IE). Subsequently, from 2019 to 2021, he experienced multiple episodes of severe fatigue and high fever, each requiring treatment with antibiotics. On admission, echocardiography revealed preserved ejection fraction with severe dysfunction of both the aortic and mitral prostheses. Blood cultures were positive for gram-positive Lactococcus garvieae, and a CT scan showed splenomegaly and multiple splenic abscesses. 

The patient underwent a Commando procedure with simultaneous splenectomy. A mechanical prosthesis was implanted in both the mitral and aortic positions, and the left atrium and aortic root were reconstructed using xenopericardium patches. 
The patient's postoperative recovery was uneventful, and he was discharged on postoperative day eight. However, four months later, he was readmitted due to weakness and fever. Echocardiography revealed vegetations on the mitral valve prosthesis leaflets (up to 8 mm) and a mild aortic valve paravalvular leak, with blood cultures positive for gram-positive Enterococcus durans. Antibiotic treatment for six weeks was recommended, after which the patient’s condition improved. 

Eighteen months after the initial Commando procedure, the patient was admitted again with severe symptoms including shortness of breath at rest, dizziness, severe weakness, nausea, vomiting, and signs of shock (BP 70/40, pale, dry skin, oliguria). Blood cultures now showed gram-positive Enterococcus faecalis, and echocardiography revealed severe dysfunction of both the mitral and aortic valve prostheses. 

An emergency re-Commando procedure was performed, during which all infected prostheses and inflammatory tissues were removed. The surgical approach included transection of the superior vena cava (SVC) to facilitate optimal exposure. Mechanical prostheses were implanted in both the mitral and aortic positions. 

During the early postoperative period, a stuck AV leaflet with moderate AV prosthesis dysfunction was detected, although the patient was stable, and his condition improved. 

Given the moderate AV regurgitation, two options were considered: 
1. Careful observation of the patient with optimal medical treatment 
2. Repeated surgery 

After consulting with colleagues and obtaining the patient's consent, a decision was made in favor of the surgery.

During the re-AVR procedure, adjustments were made to avoid previous complications related to the pledgets' position. The patient was discharged home on postoperative day nine in satisfactory condition. Given the recurrent and aggressive nature of his IE, lifelong antibiotic treatment was recommended to prevent further complications.

Two years post-procedure, the patient remains free from episodes of infective endocarditis. The Commando procedure, known for its complexity, proved effective in managing severe IE complications. 

References

1. Tirone E. David, Myriam Lafreniere-Roula, Carolyn M. David, Hugo Issa,Outcomes of combined aortic and mitral valve replacement with reconstruction of the fibrous skeleton of the heart,The Journal of Thoracic and Cardiovascular Surgery,Volume 164, Issue 5,2022,Pages 1474-1484, ISSN 0022-5223, https://doi.org/10.1016/j.jtcvs.2021.09.011.

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