Commando procedure
“COMMANDO PROCEDURE” in a Patient with Aortic and Mitral Valve Prostheses: A Fourth Intervention for Bacterial Endocarditis.
1. Right femoral artery and vein cannulation
2. Resternotomy.
3. Lysis of mediastinal adhesions.
4. Cannulation of the superior vena cava and venous sinus for retrograde cardioplegia. Circling venae cavae.
6. Initiation of cardiopulmonary bypass (CPB).
7. Administration of retrograde «del Nido» cardioplegia after aortic clamping.
8. Aortotomy.
9. Removal of Aortic mechanical prosthesis
10. Finding of the severely destroyed area of the Aortic annulus (between left and right sinuses), debridement of the annulus and removal of the infected tissue
11. Vertical extension of aortotomy until the non-coronary aortic sinus and annulus, until the dome of the left atrium
12. Opening of right atrial Wall and left atrial roof to allow access to the mitral valve
13. Removal of mechanical prosthesis
14. Reconstruction of the aortic annulus with a bovine pericardial patch using 4.0 polypropylene continuous sutures
15. Placement of U-stitches in Ethibond 2.0 with pledgets in the posterior mitral annulus
16. Implantation of a 29 mm Epic™ Plus Mitral bioprosthesis.
17. Reconstruction of the anterior portion of the mitral annulus between the anterior and posterior trigones by suturing the base of a bovine pericardial patch to the sewing cuff of the mitral prosthesis.
18. Closure of left atrium roof using 4.0 polypropylene continuous sutures
18. The “new” aortic annulus diameter is measured using dedicated valve sizers (25).
19. After aortic wall reconstruction, implantation of a PERIMOUNT Magna Ease bioprosthesis (25) using U-stitches in Ethibond 2.0 with pledegtes
20. Aortic wall reconstruction
21. Implantation of a PERIMOUNT Magna Ease Aortic bioprosthesis (25)
22. Closure of the aortotomy using 4.0 polypropylene continuous sutures
23. Closure of the right atrium using 4.0 polypropylene continuous sutures
21. Deairing maneuver and release of the Aortic clamp
22. Intraoperative transesophageal echocardiography (TEE) demonstrating the good functioning of the bioprosthesis
Cardiovascular Department ULSS 3 SERENISSIMA VENICE ITALY