Redo TAVR With Fluoroscopic-Free Surgical Resection of Prosthetic Valve Leaflets Under Direct Vision (SURPLUS) Technique

Q: What is the clinical evidence from this study?

Study design: Case Report. Population: Failed transcatheter aortic valve (TAVR) with high coronary obstruction risk (n=1). Intervention: Fluoroscopic-free SURPLUS technique. Primary outcome: Procedural success and freedom from coronary obstruction.

Q: What does this research mean for the field?

The fluoroscopic-free SURPLUS technique is a feasible and effective approach for redo TAVR in patients at high risk of coronary obstruction, providing good valve function and avoiding coronary obstruction without intraoperative fluoroscopy. Novelty: ClaimNovelty.METHODOLOGICAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Louise Bik-yu Ting; Cheuk Pang Wong; Chun‐Ka Wong; Simon Cheung-Chi Lam; Inderjeet Bhatia; Daniel Tai‐Leung Chan

doi:10.1016/j.jacasi.2026.07.008

August 20, 2026JACC AsiaOpen Access

Redo TAVR With Fluoroscopic-Free Surgical Resection of Prosthetic Valve Leaflets Under Direct Vision (SURPLUS) Technique

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Key result

Novel fluoroscopy-free SURPLUS technique prevents coronary obstruction during re-do TAVR with durable 1-year function.

n=1

Figures

Graphical abstract published by JACC Asia — Graphical abstract · Published by JACC Asia · CC BY

Key Points

To describe a completely fluoroscopic-free technique for the surgical resection of prosthetic valve leaflets under direct vision (SURPLUS) during redo transcatheter aortic valve replacement in a patient at extreme risk of bilateral coronary obstruction.
Evaluated an 80-year-old male presenting with severe transvalvular aortic regurgitation 7 years after initial transcatheter aortic valve replacement.
Identified prohibitively high bilateral coronary obstruction risk using preoperative computed tomography, with valve-to-coronary distances of 3 mm and 2 mm and coronary heights of 4 mm and 2 mm.
Performed open surgical resection of the failed leaflets under direct vision while preserving the index stent in situ, followed by balloon-expandable valve deployment without fluoroscopy.
Direct-vision valve deployment achieved successful commissural alignment and precise placement using the index valve locator as an anatomical landmark without intraoperative fluoroscopy.
Aortic cross-clamp time was 24 minutes and cardiopulmonary bypass time was 35 minutes.
The procedure resulted in zero coronary obstruction, no aortic wall damage, and demonstrated good immediate and 1-year clinical outcomes.

Study Design

Type

Case Report (n=1)

Multicenter

No

Structured PICO

P

Population

One 80-year-old man with a failed transcatheter aortic valve and high bilateral coronary obstruction risk, followed for 1 year.

I

Intervention

Fluoroscopic-free Surgical Resection of Prosthetic Valve Leaflets Under Direct Vision (SURPLUS) technique (median sternotomy, excision of failed TAV leaflets leaving the stent in situ, followed by surgical deployment of a 26-mm SAPIEN 3 Ultra Resilia balloon-expandable valve) along with left atrial appendage closure.

O

Outcome

Procedural success (coronary obstruction risk mitigation, immediate valve hemodynamics) and clinical status at 1-year follow-up.

A completely fluoroscopic-free surgical modification of the SURPLUS technique is a safe and feasible alternative to redo TAVR for patients with a degenerated transcatheter heart valve and prohibitively high risk of coronary obstruction.

Limitations

Not suitable for patients with endocarditis or patient-prosthesis mismatch.
More invasive than transcatheter approaches.
Findings are based on a single case report, limiting generalizability.
Not suitable for patients with endocarditis
Not suitable for patients with patient-prosthesis mismatch
More invasive than transcatheter approaches

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Implication

May support fluoroscopic-free SURPLUS in select high-risk redo TAVR; leaves open prospective validation before wider use.

Abstract

We report a fluoroscopic-free approach to the Surgical Resection of Prosthetic Valve Leaflets Under Direct Vision (SURPLUS) technique. With expanding transcatheter aortic valve replacement (TAVR) volumes and broader indications, a failed transcatheter prosthesis is typically managed by redo TAVR. However, when bilateral coronary obstruction risk is prohibitively high and transcatheter leaflet modification techniques such as Bioprosthetic Aortic Scallop Intentional Laceration to prevent Iatrogenic Coronary Artery obstruction or Undermining Iatrogenic Coronary Obstruction With Radiofrequency Needle, or coronary stenting, are not feasible, transcatheter aortic valve explantation remains an alternative, yet it is technically demanding and carries significant risk according to real-world data. SURPLUS was previously described as a hybrid option wherein the failed leaflets are excised while the original stent is left in situ, followed by surgical valve-in-valve deployment. Here, we describe a completely fluoroscopic-free execution of SURPLUS in an older patient with high bilateral coronary obstruction risk, detailing the method to determine implantation depth and achieve commissural alignment without fluoroscopic imaging. The procedure resulted in no coronary obstruction and demonstrated good immediate and 1-year outcomes.

Discussion

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Cite This Study

Ting et al. (2026) conducted a case report in Failed transcatheter aortic valve (TAVR) with high coronary obstruction risk (n=1). Fluoroscopic-free SURPLUS technique was evaluated on Procedural success and freedom from coronary obstruction. The fluoroscopic-free SURPLUS technique was successfully performed in an 80-year-old man with high coronary obstruction risk, resulting in no coronary obstruction and good 1-year valve function.

synapsesocial.com/papers/6ad0fcb515427f6a840402e4 https://doi.org/10.1016/j.jacasi.2026.07.008

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Redo TAVR With Fluoroscopic-Free Surgical Resection of Prosthetic Valve Leaflets Under Direct Vision (SURPLUS) Technique

Figures

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Redo TAVR With Fluoroscopic-Free Surgical Resection of Prosthetic Valve Leaflets Under Direct Vision (SURPLUS) Technique

Figures

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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