What question did this study set out to answer?

The aim is to evaluate the effectiveness of the Commando procedure in mitigating patient–prosthesis mismatch during valve replacement in a patient with small annuli.

January 10, 2026Journal of Surgical Case Reports0 citationsOpen Access

Successful double valve replacement with extensive annular enlargement using the Commando procedure in a patient with small aortic and mitral annuli after previous double valve surgery

AIAkito InoueAsahikawa Medical University DTDaisuke TakeyoshiAsahikawa Medical University HAHideki AkamatsuMusashino Red Cross Hospital

Key Result

The Commando procedure allowed successful double valve replacement with significant annular enlargement, leading to excellent hemodynamics and an asymptomatic recovery.

Key Points

The aim is to evaluate the effectiveness of the Commando procedure in mitigating patient–prosthesis mismatch during valve replacement in a patient with small annuli.
Patient underwent redo double valve replacement using the Commando procedure.
Both aortic and mitral annuli were enlarged using bovine pericardium.
Echocardiography was used to assess valve function before and after surgery.
Postoperative echocardiography showed excellent hemodynamics with an aortic effective orifice area of 1.76 cm2.
Mean gradient for the aortic valve was 6 mmHg and for the mitral valve was 3 mmHg.
The patient had an uneventful recovery and remains asymptomatic.

Structured PICO

Population

A 70-year-old woman (n=1) with progressive heart failure, severe mitral stenosis (mitral valve area 0.96 cm2), moderate aortic stenosis with moderate paravalvular leak, and small aortic and mitral annuli (body surface area 1.42 m2). History of previous double valve surgery 13 years prior (aortic valve replacement, mitral repair, and tricuspid annuloplasty).

Intervention

Redo double valve replacement with extensive annular enlargement using the Commando procedure (enlargement of both annuli with bovine pericardium, implantation of a 27 mm mitral bioprosthesis and a 23 mm aortic bioprosthesis).

Outcome

Postoperative hemodynamics (aortic effective orifice area and mean gradients) and clinical recovery.

The Commando procedure safely enables simultaneous enlargement of both aortic and mitral annuli during complex redo double valve replacement, minimizing patient-prosthesis mismatch.

Main Result

Absolute Event Rate: 0% vs 0%

Abstract

Abstract We report a 70-year-old woman (body surface area 1.42 m2) undergoing redo double valve replacement with extensive annular enlargement using the Commando procedure. Thirteen years earlier, she received aortic valve replacement (St. Jude Medical 19 mm), mitral repair (Physio Ring 24 mm), and tricuspid annuloplasty. She presented with progressive heart failure; echocardiography showed severe mitral stenosis (mitral valve area 0.96 cm2) and moderate aortic stenosis with moderate paravalvular leak. To avert patient–prosthesis mismatch (PPM), both annuli were enlarged with bovine pericardium, permitting implantation of an Epic 27 mm mitral and an Inspiris 23 mm aortic bioprosthesis. Postoperative echocardiography demonstrated excellent hemodynamics (aortic effective orifice area 1.76 cm2, mean gradient 6 mmHg; mitral mean gradient 3 mmHg). Recovery was uneventful, and she remains asymptomatic. Commando surgery enabled safe, simultaneous enlargement of both annuli, minimizing PPM, and preserving options for future valve-in-valve therapy.

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