Successful combined aortic and mitral valve replacement with biological prostheses using the COMMANDO procedure under conditions of narrow valve rings and severe calcification via a mini-sternotomy approach: a case report

Authors

DOI:

https://doi.org/10.66636/gmj.v1.i3.a198

Keywords:

acquired heart valve disease, aortic valve stenosis, mitral valve stenosis, COMMANDO procedure, aorto-mitral fibrous continuity reconstruction, prosthesis-patient mismatch, biological prosthesis, mini-sternotomy, minimally invasive cardiac surgery, case report

Abstract

Background: Simultaneous acquired aortic and mitral valve disease complicated by severe calcification and anatomically narrow rings poses a significant technical challenge in adult cardiac surgery. Implantation of small-sized prostheses under standard double-valve replacement risks prosthesis-patient mismatch (PPM), associated with elevated transprosthetic gradients, impaired regression of left ventricular hypertrophy, and reduced long-term survival. Reconstruction of the aorto-mitral fibrous continuity — the COMMANDO procedure — is the definitive surgical strategy to circumvent this limitation.

Case presentation: A 73-year-old female with severe biValvular calcification and critically narrow annular dimensions (aortic 21 mm; mitral 34 mm) underwent combined aortic and mitral bioprosthetic replacement via the COMMANDO technique through a partial upper mini-sternotomy. An autopericardial patch was used to reconstruct the intervalvular fibrosa and simultaneously enlarge both annuli. Hancock II bioprostheses were implanted (mitral 29 mm; aortic 25 mm). Cardiopulmonary bypass time was 150 minutes; cross-clamp time 135 minutes; intraoperative blood loss 200 mL. The heart resumed sinus rhythm spontaneously without inotropic support. The patient was extubated on postoperative day 1 and discharged on day 9. Follow-up echocardiography confirmed excellent prosthetic function (aortic PGmean 11 mmHg; mitral PGmean 3 mmHg; no paravalvular leak) with definitive avoidance of PPM (aortic iEOA 1.85 cm2/m2; mitral iEOA 2.5 cm2/m2).

Conclusion: The COMMANDO procedure executed through a partial upper mini-sternotomy is safe and technically feasible in elderly patients with severe biValvular calcification and narrow annular dimensions, enabling optimal prosthesis sizing, definitive PPM prevention, and excellent early haemodynamic outcomes.

Keywords: acquired heart valve disease; aortic valve stenosis; mitral valve stenosis; COMMANDO procedure; aorto-mitral fibrous continuity reconstruction; prosthesis-patient mismatch; biological prosthesis; mini-sternotomy; minimally invasive cardiac surgery; case report

References

1. David TE, Kuo J, Armstrong S. Aortic and mitral valve replacement with reconstruction of the intervalvular fibrosa. J Thorac Cardiovasc Surg. 1997;114(5):766-772. https://doi.org/10.1016/S0022-5223(97)70080-1 DOI: https://doi.org/10.1016/S0022-5223(97)70080-1

2. De Oliveira NC, David TE, Armstrong S, Ivanov J. Aortic and mitral valve replacement with reconstruction of the intervalvular fibrosa: long-term results. J Thorac Cardiovasc Surg. 2005;129(4):851-855. https://doi.org/10.1016/j.jtcvs.2004.07.034 DOI: https://doi.org/10.1016/j.jtcvs.2004.09.032

3. Davierwala PM, Binner C, Subramanian S, Dahmen G, Haensig M, Pfannmueller B, et al. Double valve replacement and reconstruction of the intervalvular fibrosa: the "Commando" procedure. J Thorac Cardiovasc Surg. 2014;148(5):2046-2053. https://doi.org/10.1016/j.jtcvs.2014.02.079 DOI: https://doi.org/10.1016/j.jtcvs.2014.02.079

4. Pibarot P, Dumesnil JG. Prosthesis-patient mismatch: definition, clinical impact, and prevention. Heart. 2006;92(7):1022-1029. https://doi.org/10.1136/hrt.2005.067363 DOI: https://doi.org/10.1136/hrt.2005.067363

5. Forteza A, Centeno J, Ospina V, Lunar IG, Sanchez V, de Diego J, et al. Outcomes of the "Commando" procedure for reconstruction of the intervalvular fibrosa. Ann Thorac Surg. 2020;110(3):872-878. https://doi.org/10.1016/j.athoracsur.2019.12.031 DOI: https://doi.org/10.1016/j.athoracsur.2019.12.031

6. Navia JL, Elgharably H, Hakim AH, Griffin B, Rodriguez LL, Pettersson GB. Long-term outcomes of the "Commando" procedure for complex aortic and mitral valve disease. J Thorac Cardiovasc Surg. 2021;162(5):1423-1432. https://doi.org/10.1016/j.jtcvs.2020.03.164 DOI: https://doi.org/10.1016/j.jtcvs.2020.03.164

7. Glauber M, Miceli A, Gilmanov D, Ferrarini M, Bevilacqua S, Farneti PA, et al. Right anterior minithoracotomy versus conventional aortic valve replacement: a propensity score matched study. J Thorac Cardiovasc Surg. 2013;145(5):1222-1226. https://doi.org/10.1016/j.jtcvs.2013.01.040 DOI: https://doi.org/10.1016/j.jtcvs.2012.03.064

8. Riley DS, Barber MS, Kienle GS, Aronson JK, von Schoen-Angerer T, Tugwell P, et al. CARE 2013 explanations and elaborations: reporting guidelines for case reports. J Clin Epidemiol. 2017;89:218-235. https://doi.org/10.1016/j.jclinepi.2017.04.026 DOI: https://doi.org/10.1016/j.jclinepi.2017.04.026

9. Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, et al. 2021 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J. 2022;43(7):561-632. https://doi.org/10.1093/eurheartj/ehab395 DOI: https://doi.org/10.1093/ejcts/ezac209

10. Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP 3rd, Gentile F, et al. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease. J Am Coll Cardiol. 2021;77(4):e25-e197. https://doi.org/10.1016/j.jacc.2020.11.018 DOI: https://doi.org/10.1016/j.jacc.2020.11.018

11. Chen Y, Chang C, Lin Y, Yang AH, Tsai TP, Chu JJ. Reconstruction of the intervalvular fibrosa (Commando procedure) in severe calcification and prosthesis-patient mismatch. Gen Thorac Cardiovasc Surg. 2018;66(9):512-519. https://doi.org/10.1007/s11748-018-0951-y

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08/24/2026

How to Cite

Gabaidze, G., Nachkebia, B., Kadjaia, M., Giorgadze, G., Khozrevanidze, G., & Kiria, D. (2026). Successful combined aortic and mitral valve replacement with biological prostheses using the COMMANDO procedure under conditions of narrow valve rings and severe calcification via a mini-sternotomy approach: a case report. Georgian Medical Journal, 1(3). https://doi.org/10.66636/gmj.v1.i3.a198

Issue

Vol. 1 No. 3 (2026): Surgical Innovation, Paediatrics, and Environmental Health

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Case Reports

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Copyright (c) 2026 Giorgi Gabaidze, Bachuki Nachkebia, Medea Kadjaia, Giorgi Giorgadze, Giga Khozrevanidze, Dimitri Kiria

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