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

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.