Evolving Redo Frame-Preserving Leaflet Resection: From Transcatheter to Surgical Aortic Valves

Redo aortic valve replacement after bioprostheses failure carries high risk from friable tissue, pannus ingrowth, and potential root reconstruction. Building on the Surgical Resection of Prosthetic Valve Leaflets Under Direct Vision (SURPLUS) technique for failed transcatheter valves, we describe a novel evolution for failed surgical bioprostheses: Surgical Valve Preservation and Resection of Bioprosthetic Leaflets (SUPERB). In SUPERB, degenerated leaflets are excised while the supporting ring is preserved, permitting deployment of a balloon-expandable prosthesis under direct vision.

Between January 2023 and August 2025, 3 high-risk patients with degenerated aortic valves underwent redo replacement at a tertiary center: 2 with failed surgical bioprostheses (SUPERB) and 1 with a failed transcatheter prosthesis (SURPLUS). All were unsuitable for valve-in-valve transcatheter replacement due to low coronary heights, pannus ingrowth, or small annuli. Operative details, perioperative course, and follow-up echocardiography were reviewed.

All patients underwent successful leaflet excision with balloon-expandable valve deployment and confirmed coronary patency. Cross-clamp and cardiopulmonary bypass times were minimized vs conventional explantation, and no annular disruption or root replacement was required. Postoperative complications included transient acute kidney injury (n = 2), delirium (n = 1), hypotension (n = 1), and urinary retention (n = 1). All were discharged to rehabilitation. At follow-up, the prostheses remained functional with preserved ventricular performance and no valvular regurgitation.

The SUPERB technique extends the SURPLUS concept to failed surgical bioprostheses, providing hybrid alternatives to complete prosthesis explantation. These strategies may reduce operative risk by shortening cross-clamp and bypass times, preserving coronary access, and avoiding root reconstruction. Multicenter evaluation is warranted.