Outcomes of combined aortic and mitral valve replacement with reconstruction of the fibrous skeleton of the heart

Published:September 22, 2021DOI:



      The objectives of this study were to examine operative and long-term results of combined aortic and mitral valve replacement when reconstruction of the fibrous skeleton of the heart is needed because of calcification, abscess, previous operations, or patient-prosthesis mismatch.


      From 1985 to 2020, 182 consecutive patients underwent combined aortic and mitral valve replacement with reconstruction of the intervalvular fibrous skeleton in all cases and also the posterior mitral annulus in 63 patients. Bovine pericardium or Dacron grafts were used for the reconstructions. Median follow-up was 7.5 (interquartile range, 2.1-12.6) years and 98% complete.


      Patient mean age was 62 years; 69% had 1 or more previous valve operations, and 92% were functional class III or IV. The indications for reconstruction were extensive calcification of the fibrous skeleton in 34%, abscess in 13%, tissue damage secondary to previous operations in 39%, and patient-prosthesis mismatch of the mitral valve in 13%. Bovine pericardium was used in two-thirds of cases and Dacron grafts in one-third. Operative mortality was 13.2% and postoperative complications were common. Survival at 1, 10, and 20 years was 81.8%, 51.1%, and 23.7%, respectively. Fourteen patients required reoperation and 3 transcatheter interventions. The cumulative probability of reinterventions at 1, 10, and 20 years were 3.3%, 5.8%, and 9.1%, respectively. Most patients experienced symptomatic improvement postoperatively.


      Reconstructions of the fibrous skeleton of the heart are associated with high operative mortality but the long-term results are satisfactory because most patients would not have survived without surgical intervention.

      Graphical abstract

      Key Words

      Abbreviations and Acronyms:

      CI (confidence interval), HR (hazard ratio), IQR (interquartile range)
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      Linked Article

      • Commentary: U can't touch this
        The Journal of Thoracic and Cardiovascular SurgeryVol. 164Issue 5
        • Preview
          Many times in his 1990 hit of the same name, MC Hammer intoned: “U can't touch this!”1 Readers might agree while reviewing Tirone David’s 35-year experience with aortic-mitral valve replacement and reconstruction of the intravalvular fibrous body.2 David and colleagues,3 who first described the procedure in 1997, detail the various iterations of the procedure, provide illustrations, and report 1-, 10-, and 20-year survival of 81.8%, 51.1%, and 23.7%, respectively.
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      • Commentary: Evolution of surgical technique in the hands of an expert
        The Journal of Thoracic and Cardiovascular SurgeryVol. 164Issue 5
        • Preview
          David and colleagues1 from Toronto provide an update on the team's single-surgeon series of patients with double valve (aortic and mitral) replacement and reconstruction of the fibrous skeleton of the heart. The approach used, which has been dubbed elsewhere “commando” or “UFO” due to a complexity that takes most surgeons out of their comfort zone, has been perfected over the years by Dr David. His early series was described in 1997 and included 43 patients.2 A follow-up series was published in 2005 and included 73 patients.
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