Aortic Prosthesis Endocarditis With Aorto-Mitral Fibrosa Abscess and Left Atrial Fistula

BACKGROUND: Complicated infective endocarditis (IE) with involvement of the aorto-mitral curtain is associated with high morbidity and mortality rates. Double-valve surgery with reconstruction of the aorto-mitral fibrosa is an uncommon and challenging procedure. CASE SUMMARY: A 70-year-old woman with a history of 2 cardiac surgeries presented with IE involving an aortic bioprosthesis and an extensive abscess of the aorto-mitral fibrosa. The patient underwent a Commando procedure, involving the replacement of the aortic valve with reconstruction of the intervalvular fibrosa through a pericardial patch. DISCUSSION: The surgical procedure required radical debridement to obtain drainage of the abscess and eradication of infected biofilm and to avoid reinfection. Although technically demanding and associated with high perioperative mortality, this surgical intervention was the only radical and suitable option available. The patient, despite having undergone a third surgical procedure, had a typical postoperative course, with no recurrence of infection at 1-year follow-up. TAKE-HOME MESSAGES: This case highlights how IE involving the aorto-mitral fibrosa, although rare, can be extremely complex and requires urgent surgical correction. Surgical treatment with the Commando procedure is technically demanding, with high perioperative morbidity and mortality, but it is the only radical treatment option.