What is the Commando procedure in surgical practice?

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Last updated: October 19, 2026 • View editorial policy

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What is a Commando Procedure?

The Commando procedure is a complex cardiac operation involving simultaneous replacement of both the aortic and mitral valves combined with reconstruction of the intervalvular fibrosa (the fibrous tissue connecting these two valve annuli), creating a single large opening into the left ventricle that is then reconstructed with a patch. 1

Anatomical Basis

The procedure divides the intervalvular fibrosa, converting the aortic and mitral orifices into one large opening into the left ventricle. Notably, the planes of the mitral and aortic annuli are at right angles to each other, which is a critical anatomical consideration during reconstruction. 1

Primary Indications

The Commando procedure is reserved for severe, complex pathology affecting both valves and the fibrous skeleton:

  • Extensive mitral annular calcification (MAC) extending into the aortic annulus and intervalvular fibrosa 1
  • Radiation heart disease with calcification of both valves and the aortomitral curtain 2
  • Endocarditis with destruction of the intervalvular fibrosa (most common indication in recent series - 78.4% of cases) 3
  • Small aortic and mitral annuli requiring upsizing for adequate prosthesis implantation 4, 5
  • Redo valve surgery in patients with inadequate annular tissue 5

Technical Approach

The standard technique involves:

  1. Exposure through aortotomy and left atrial dome
  2. Removal of both aortic and mitral valves
  3. Debridement of diseased tissue including the intervalvular fibrosa
  4. Reconstruction of the fibrous skeleton using bovine pericardial patch
  5. Replacement of both valves with appropriately sized prostheses 2, 6

Technical Modifications

The "Chimney" modification has emerged as an important advancement, particularly for patients with small annuli or prior valve surgery. This technique uses a self-assembled valved conduit and has demonstrated significantly lower permanent pacemaker rates (6.3% vs 28.3% with traditional approach). 5, 7

The modified Commando can be combined with a Konno procedure to further enlarge the aortic annulus when needed. 4

Clinical Outcomes

Mortality

  • Operative mortality: 13.5% in recent series, with all deaths occurring in the endocarditis group 3
  • Survival rates: 80.3% at 1 year, 59.2% at 3-5 years 3

Major Complication: Permanent Pacemaker Requirement

One in five patients (22.3%) requires permanent pacemaker implantation due to atrioventricular block from proximity to the conduction system during fibrous skeleton reconstruction. 7

The Chimney modification substantially reduces this risk to 6.3%. 7

Other Complications

Atrioventricular groove (AVG) disruption is the most lethal complication, with mortality approaching 90% despite repair attempts. 1

Critical Pitfalls

  • Conduction system injury is nearly unavoidable given the proximity of the His bundle to the intervalvular fibrosa—anticipate need for permanent pacing
  • Incomplete debridement of infected or calcified tissue risks recurrent infection or paravalvular leak
  • Inadequate patch reconstruction can lead to left ventricular-left atrial communication
  • This procedure should only be performed at experienced centers with structural heart teams available for bailout 1

When to Consider

The Commando procedure is indicated when:

  • Conventional double valve replacement is technically impossible due to extensive tissue destruction
  • The intervalvular fibrosa is involved in the pathologic process (infection, calcification, radiation damage)
  • Annular enlargement is necessary to accommodate adequate-sized prostheses
  • The patient has anatomy unsuitable for transcatheter approaches 1

References

2
Research

Commando procedure for radiation heart disease.

Multimedia manual of cardiothoracic surgery : MMCTS, 2024

4
Research

Reconstruction of Fibrous Skeleton of the Heart for Double-Valve Replacement in A Pediatric Patient - Modified Commando Procedure.

Seminars in thoracic and cardiovascular surgery. Pediatric cardiac surgery annual, 2024

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.