Easy in, hard out: commando procedure for invasive endocarditis of transcatheter aortic valve

Simpson et al. (1) reported a case of prosthetic aortic valve endocarditis in a patient with prior transcatheter aortic valve implantation (TAVI). With the significant increase in the rates of TAVI (2), the incidence of TAVI endocarditis is expected to be on the rise. These cases represent a unique challenge secondary to the invasive pathology commonly associated with prosthetic valve endocarditis, such as aortic root abscess (3), and the complexity associated with TAVI explant. TAVI explant is associated with 11% in-hospital and 13% 30-day mortality (4). In addition, patients who received TAVI could present with co-morbidities such as older age, frailty, and chronic disease. Thus, surgery for TAVI endocarditis carries high-risk morbidity and mortality.

TAVI explant

Different techniques have been reported for explant of TAVI (5-7). The goal is to preserve the integrity of the aortic root wall, aortic annulus, and the left ventricular outflow tract (LVOT) to allow implantation of a new prosthetic aortic valve without the need for complex reconstruction or replacement of the aortic root. Simpson et al. (1) used careful blunt dissection to explant the TAVI. Similarly, our approach is to use a blunt elevator (spatula) to get in the right plane between the aortic wall and the TAVI frame, then between the native aortic valve leaflets and the TAVI frame. Holding the frame with a Kelly clamp, the spatula is used to dissect the TAVI lower frame or skirt off the LVOT without injury to the annulus or the muscle. The TAVI is then pulled out and sent for microbiology and pathology examination (8). While the fundamental principles of transcatheter aortic valve replacement (TAVR) explant remain consistent across valve platforms, important technical nuances differ between self-expanding and balloon-expandable devices. The skirt of the balloon-expandable valves (e.g., SAPIEN) becomes firmly embedded within the annulus due to fibrous tissue ingrowth and integration with the surrounding calcified tissue, necessitating meticulous sharp dissection to free the frame and minimize the risk of annular or LVOT injury. Self-expanding valves (e.g., Evolut), by virtue of their supra-annular positioning and longer nitinol frame extending into both the LVOT and ascending aorta, require careful circumferential dissection along the entire frame length, which may necessitate a higher aortotomy.

TAVI endocarditis

The microbiological profile of TAVI endocarditis carries important implications for surgical timing and outcomes. Staphylococcal species, Streptococcus, and Enterococcus faecalis are the most frequently identified pathogens (9). Enterococcal endocarditis, as in the case presented by Simpson et al. (1), poses particular challenges given its biofilm-forming properties and tendency for invasive disease. Prolonged organism-specific intravenous antibiotic therapy, guided by the endocarditis team, is mandatory before and after surgery. In cases of active uncontrolled infection or hemodynamic deterioration, surgery should not be delayed awaiting microbiological sterilization, as source control through surgical debridement is itself a critical component of treatment (9). The invasive pathology associated with TAVI endocarditis could be focal, which can be addressed with patch reconstruction of the aortic annulus and aortic valve replacement after careful explant of the TAVI and adequate debridement (8). However, it could also present with circumferential aortic root abscess, which may require reconstruction of the aortic root with an allograft, or invasion of the inter-valvular fibrosa into the anterior mitral leaflet, as in the case video presented by Simpson et al. In that instance, the Commando procedure is indicated to reconstruct the inter-valvular fibrosa along with double valve replacement (10,11).

The Commando procedure

The technique of the Commando procedure is based on the Manougian aortic root enlargement, which extends the aortotomy posteriorly into the anterior mitral leaflet, allowing adequate debridement of infection or calcification of the inter-valvular fibrosa, as well as replacement of the aortic and mitral valves (10). In the setting of invasive pathology of the aortic root extending into the anterior mitral leaflet, the Commando procedure is of particular value (11). However, the Commando procedure in the setting of infective endocarditis can be technically demanding due to fragility of the tissue, including the fibrous trigones. Thus, certain technical aspects of the Commando procedure are to be considered when planning for an endocarditis case.

The Commando exposure provides adequate exposure for the debridement of infected tissues, which is crucial for the integrity of the planned reconstruction and avoiding postoperative bleeding or peri-valvular leak. Mitral prosthesis implanted through the Commando exposure, using 1/4–1/3 of the length of the anterior prosthesis cuff to reconstruct the new inter-valvular fibrosa (Figure 1) (10). Oversizing of the mitral prosthesis (using more than 1/3 of the anterior mitral prosthesis cuff as the new inter-trigonal distance) can cause LVOT obstruction and tension on the reconstruction suture lines. Our approach is to implant the mitral prosthesis and leave the anterior 1/4 of the prosthesis cuff to sew the patch that will reconstruct the new inter-valvular fibrosa (12). Simpson et al. (1) chose to sew the patch on the mitral prosthesis on the back table. Other groups described a similar technique (10). We typically would enforce the right and left trigones with additional pledget sutures after implantation of the mitral prosthesis (13).

Figure 1 Mitral prosthesis implanted through commando exposure. Dashed line: roof of left atrium. Asc Ao, ascending aorta; LA, left atrium; LVOT, left ventricular outflow tract; RA, right atrium; RV, right ventricle.

After reconstruction of the inter-valvular fibrosa with patch (pericardial or graft material), the remainder of the patch is used to reconstruct the aortic root wall and allow for up-sizing of the aortic prosthesis. We leave no more than 0.5–1 cm between the aortic and mitral prostheses to avoid over-tilting of the aortic prosthesis, which could complicate future TAVI valve-in-valve. The goal is to implant the aortic prosthesis in the annular plane. Furthermore, excessive separation between the aortic and mitral prostheses may predispose to dynamic LVOT obstruction due to mitral prosthesis mobility. The superior margin of the patch is then utilized to close the aortotomy (12,13). Simpson et al. (1) used a second patch to close the aortotomy. We tend to leave the Commando patch large, which can be trimmed and tailored to the aortotomy incision after implanting the aortic prosthesis.

In summary, TAVI endocarditis cases can present a complex pathology in a sick patient with co-morbidities, which could require a complex operation to explant the infected TAVI, then reconstruct the damaged aortic root and inter-valvular fibrosa. The incidence of TAVI endocarditis is expected to rise. Given the complexity of these cases, thorough evaluation is necessary before surgery, and early referral to specialized centers is advised.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Visualized Surgery. The article has undergone external peer review.

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Funding: None.

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