Two variations of Commando-Nicks approach for calcified aortic and mitral valve disease.

Surgery for radiation-associated valve disease is technically demanding due to challenging exposure, extensive calcification, and risk of paravalvular leak or atrioventricular groove disruption. An oblique aortotomy revealed heavy calcification extending to the aortomitral continuity, where only a 23 mm sizer could barely pass. The aortotomy was extended into the non-coronary sinus adjacent to the left-non commissure. An extended transseptal approach was employed and connected to the aortotomy. The anterior mitral leaflet was excised. From trigone to trigone, non-everting buttressed stitches were placed in the posterior annulus to avoid the mitral annular calcification. A 2-cm-wide felt strip collar, corresponding to the mitral annular calcification depth, was secured to a 31 mm mitral bioprosthesis with running polypropylene sutures. The valve stitches were passed through the felt strip, and after tying them down, a folded bovine pericardial patch was sewn to the anterior annulus of the mitral prosthesis using a running suture. One side of the patch was used to close the dome of the left atrium; the other side was used to close the aortotomy. A 27 mm aortic prosthesis was then easily implanted due to root enlargement. The aortotomy was closed, and the patient was weaned from cardiopulmonary bypass without difficulty.