Commando Anesthesia: The Challenge of Replacing the Aortic Root and Three Valves

Authors

• Michael Pellizzari, Michigan State University College of Human Medicine Medical Student
• Garrett Miedema, Michigan State University College of Human Medicine Medical Student
• Mark Wedder, Anesthesiology - Corewell Health West
• Nicholas Watson, Anesthesiology - Corewell Health West

Document Type

Conference Proceeding - Restricted Access

Publication Date

5-8-2026

Abstract

Aortic root abscess (ARA) is a severe manifestation of periannular spread of infectious endocarditis (IE). ARA arises in 10-40% of cases of IE. Complications of ARA include the formation of root-to-atrium/ventricle fistula(s) in approximately 10% of patients. The "commando procedure", a complex, high risk surgery to address the destruction of the aortomitral fibrous body, carries significant risks including bleeding, reinfection, patch dehiscence, and high rates of mortality. Accordingly, the anesthetic management demands meticulous technique customized to the patient's unique needs.

An 82 YOM with a PMH of CAD s/p CABG x2/AVR, EVAR x2, HFpEF, stage III CKD, and HTN presented with progressive dyspnea and orthopnea. He was afebrile and hemodynamically stable in the ED with first degree AVB. Workup demonstrated IE with Streptococcus anginosus and aortic root abscess with two fistulas, one communicating with each atrium. On hospital day 2, the patient developed a complete heart block requiring temporary pacing, presumed secondary to extension of the infection into the AV node conduction system. Right heart catheterization revealed 1 of 2 bypass grafts patent, elevated filling pressures, and mild pulmonary hypertension. He developed AKI following multiple contrast exposures for imaging. Following preop optimization, the patient was in respiratory distress: sitting upright in bed, two-word dyspnea on BIPAP, with SpO2 90% and pulmonary edema. Preoperative counseling included an estimated 50% mortality rate for the commando procedure.

This commando procedure highlights the importance of applying basic physiologic management in the context of complex surgery. Manipulation of preload, afterload, rate, contractility, and oxygenation serves as the foundation for safe anesthesia. Diligent application tailored to the patient's unique pathologies allows operative teams to achieve desirable outcomes as demonstrated in this case.

Recommended Citation

Pellizzari M, Miedema G, Wedder M, Watson N. Commando anesthesia: The challenge of replacing the aortic root and three valves. Presented at: Research Day Corewell Health West; 2026 May 8; Grand Rapids, MI.

Comments

2026 Research Day Corewell Health West, Grand Rapids, MI, May 8, 2026. Abstract 2053