Bridging present and future: a case report of CT-Guided "Chimney" Commando for prosthetic sustainability in the transcatheter age.

BACKGROUND

Re-operative double-valve replacement in patients with small annuli and concomitant left ventricular outflow tract (LVOT) obstruction represents a significant surgical challenge. The classic Commando procedure entails high risk in re-operative settings with dense fibrosis. The "Chimney" Commando technique provides a modular alternative for anatomical reconstruction. This case emphasizes the role of computed tomography angiography (CTA) with digital twin simulation in preoperative planning and explores the concept of "prosthetic sustainability" as a proposed extension of lifetime valve management, aiming to address the immediate pathology while preserving anatomical feasibility for potential future transcatheter interventions.

CASE PRESENTATION: A 65-year-old woman with a four-decade cardiac surgical history presented with severe prosthetic valve dysfunction due to pannus overgrowth. Preoperative planning with virtual valve implantation predicted catastrophic neo-LVOT obstruction with conventional surgery, contraindicating standard approaches. A CT-guided "Chimney" Commando procedure was performed, involving the construction of a valved conduit to enlarge the annuli and reconfigure the LVOT. The patient recovered uneventfully. Postoperative imaging demonstrated a patent outflow tract, and subsequent simulation suggested that the reconstructed anatomy may be favorable for potential future valve-in-valve procedures.

CONCLUSIONS

This case illustrates the feasibility of a CTA-guided "Chimney" Commando strategy in a high-risk, anatomically complex re-operative double-valve setting. By integrating virtual simulation with an LVOT-oriented reconstruction, this approach successfully mitigated the immediate risk of obstruction and may help preserve the anatomical substrate for future transcatheter valve-in-valve interventions.