Intraoperative Indocyanine Green Near-Infrared Angiography for Redo Valve Replacement

Abstract

Background

Redo aortic interventions after failed transcatheter aortic valve replacement (TAVR) are challenging, particularly with low coronary heights and dense frame ingrowth.

Case Description

An 83-year-old woman with prior TAVR developed severe prosthetic stenosis. Surgical Resection of Prosthetic Valve Leaflets Under Direct Vision (SURPLUS) with implantation of a balloon-expandable aortic valve and intraoperative low-dose indocyanine green (ICG) near-infrared (NIR) angiography was performed. Real-time NIR imaging confirmed symmetric coronary opacification. The valve was well seated with improved ejection fraction (60–65%), and recovery was uneventful.

Conclusion

SURPLUS with ICG–NIR angiography ensured coronary patency and safe hemodynamic restoration.

Keywords

cardiovascular surgery - aortic valve and root - geriatric (includes elderly) - imaging (all modalities)

Introduction

With the expanding use of transcatheter aortic valve replacement (TAVR), clinicians are increasingly encountering structural valve deterioration and prosthesis failure. Options for reintervention include redo TAVR (TAV-in-TAVR) and surgical explantation, each with limitations. Explantation of embedded nitinol frames often requires complex root work and is associated with 30-day mortality up to 17% and 1-year mortality approaching 30%.[1] [2] Conversely, redo TAVR can be complicated by coronary obstruction when coronary heights are low or sinus sequestration occurs.

The SURPLUS technique (Surgical Resection of Prosthetic Valve Leaflets Under Direct Vision) has emerged as a hybrid strategy: Leaflets are excised under cardioplegic arrest, the frame is left in place, and a new valve is deployed inside, allowing controlled commissural alignment and coronary protection.[3] Intraoperative indocyanine green (ICG) near-infrared (NIR) angiography is established for graft assessment in coronary surgery but is rarely used for valve procedures.[4] [5] We report an octogenarian treated with SURPLUS plus ICG angiography to confirm coronary patency before separation from bypass.

Case Presentation

An 83-year-old woman with a history of TAVR using a 26-mm self-expanding Evolut (Medtronic, Minneapolis, MN) prosthesis in 2019 presented with progressive exertional dyspnea and intermittent chest tightness. Her medical history included coronary artery disease treated with a left anterior descending drug-eluting stent, heart failure with reduced ejection fraction (∼45%), biventricular implantable cardioverter-defibrillator implantation, hypertension, hyperlipidemia, left bundle branch block, patent foramen ovale, and a stable intracranial aneurysm. She was on guideline-directed medical therapy, including aspirin and prasugrel, following a recent percutaneous coronary intervention.

Electrocardiography demonstrated a paced rhythm, and serial troponins were negative. Transthoracic echocardiography showed severe prosthetic aortic stenosis with preserved left ventricular systolic function (ejection fraction 45–50%). A positron emission tomography scan revealed preserved myocardial flow reserve without new ischemia. Multidetector computed tomography demonstrated extremely low coronary heights and near-circumferential pannus and frame ingrowth surrounding the Evolut prosthesis, making redo-TAVR technically unsafe and complete explantation high-risk. Following multidisciplinary heart-team evaluation, the decision was made to proceed with a SURPLUS procedure utilizing a balloon-expandable Sapien S3 valve (Edwards Lifesciences, Irvine, CA) with intraoperative ICG–NIR angiography to verify coronary perfusion.

Through a median sternotomy, cardiopulmonary bypass was initiated, and myocardial protection was achieved with Del Nido cardioplegia. A transverse aortotomy was performed approximately 2 cm above the Evolut frame. Intraoperative inspection revealed dense, circumferential frame ingrowth precluding safe removal of the prior prosthesis, and all three degenerated bioprosthetic leaflets were excised at the cuff–cage junction. Both coronary ostia were probed and found to be patent but with critically low take-off heights. A 23-mm Sapien S3 valve (Edwards Lifesciences, Irvine, CA) was then prepared and deployed within the retained Evolut frame under direct vision with commissural alignment and an additional +2 mL postdilation to ensure full expansion. The prosthesis was secured to the underlying frame and aortic wall using interrupted 4–0 polypropylene sutures to enhance stability and prevent migration.

Before separation from cardiopulmonary bypass, a 3-mg intravenous bolus of ICG was administered. NIR fluorescence imaging demonstrated prompt, symmetric opacification of both coronary arteries without perfusion delay or defect, confirming preserved patency ([Fig. 1]). The aortotomy was closed in standard fashion, the heart was de-aired, and the aortic cross-clamp was removed. The patient was weaned from bypass uneventfully. Intraoperative transesophageal echocardiography confirmed a well-seated Sapien S3 valve with a peak gradient of 23 mm Hg and a mean gradient of 12.3 mm Hg, normal leaflet motion, no paravalvular or transvalvular regurgitation, and an improved left ventricular ejection fraction of 60% to 65%.

Fig. 1 Intraoperative images and near-infrared fluorescence angiography during SURPLUS for failed TAVR. (A) Intraoperative surgical view demonstrating the transverse aortotomy above the prior Evolut frame. The left anterior descending (LAD) artery (green arrow) and the first diagonal (blue arrow) are identified. A pacemaker lead can be seen (black arrow). (B) Near-infrared imaging following intravenous indocyanine green (ICG) bolus demonstrates symmetric, prompt opacification of the LAD (green arrow), diagonal (blue arrow), and right coronary artery (yellow arrow) without delay or perfusion defect, confirming bilateral coronary patency after SURPLUS leaflet excision. The pacemaker lead is again visualized (black arrow). ICG, indocyanine green; LAD, left anterior descending artery; SURPLUS, Surgical Resection of Prosthetic Valve Leaflets Under Direct Vision; TAVR, transcatheter aortic valve replacement.

The postoperative course was uncomplicated. The patient remained hemodynamically stable without evidence of myocardial infarction, stroke, or renal dysfunction and was discharged home following routine recovery.

Discussion

This case highlights the value of SURPLUS in managing failed self-expanding TAVR when low coronaries and frame ingrowth preclude redo TAVR or safe explant. Leaflet excision under direct vision allowed safe Sapien deployment with commissural alignment while preserving coronary access.[3]

Alternative coronary-protection strategies have been developed for patients at high risk of coronary obstruction during TAVR. Catheter-based techniques such as chimney (snorkel) stenting, prophylactic coronary wiring with undeployed stents or balloons, and BASILICA (bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary obstruction) can be effective in selected anatomies by maintaining or restoring coronary perfusion.[4] [5] These approaches are particularly useful when coronary access is feasible, and leaflet modification or ostial scaffolding is technically possible.[4] [5] However, they may be limited in the setting of severe frame ingrowth, extremely low coronary heights, or redo surgical procedures, where catheter-based manipulation carries prohibitive risk or may not achieve durable results. In such scenarios, the SURPLUS combined with the ICG strategy provides direct surgical exposure with real-time intraoperative confirmation of coronary perfusion, offering a complementary option when traditional coronary-protection techniques are not suitable.

The adjunctive use of ICG–NIR angiography provided real-time visualization of coronary perfusion, a capability that TEE alone cannot offer. Unlike angiography, ICG requires no catheterization or iodinated contrast and can be repeated intraoperatively.[6] [7] In clinical practice, ICG assessment is primarily qualitative, with interpretation based on the pattern and symmetry of opacification rather than absolute numerical thresholds. While quantitative perfusion metrics are being explored in other fields, standardized, validated quantitative criteria for coronary assessment during valve surgery are not yet established. In the present case, qualitative assessment was clinically appropriate because the principal objective was to confirm immediate, bilateral coronary opacification before separation from cardiopulmonary bypass. Within this context, the observation of prompt and symmetric filling was sufficient to guide intraoperative decision-making.

SURPLUS plus ICG fills a gap between redo TAVR and high-risk explantation. It is particularly applicable to patients with failed self-expanding TAVR who have very low coronary heights, sinus sequestration risk, or extensive frame/pannus ingrowth, in whom redo-TAVR or full explantation carries prohibitive risk. Although limited to single-patient experience, the technique may broaden options for octogenarians with challenging anatomy.

Conclusion

SURPLUS with intraoperative ICG angiography enabled safe treatment of failed Evolut TAVR in an octogenarian with very low coronaries and an embedded frame. This hybrid approach avoided root replacement, reduced the risk of coronary obstruction, and provided real-time assurance of coronary perfusion. ICG-guided SURPLUS may be integrated into multidisciplinary strategies for complex redo aortic interventions.

Contributors' Statement

B.S. contributed to methodology, project administration, visualization, and writing—review and editing. A.S. contributed to conceptualization, data curation, formal analysis, methodology, project administration, writing—original draft, and writing—review and editing. T.C. contributed to conceptualization, methodology, project administration, supervision, validation, visualization, and writing—review and editing.

Conflict of Interest

The authors declare that they have no conflict of interest.

Ethical Approval

IRB approval was waived for this single-patient case report.

Informed Consent

Written informed consent for publication was obtained.

• References

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• 4 Gherasie FA, Achim A. TAVR interventions and coronary access: How to prevent coronary occlusion?. Life (Basel) 2023; 13 (07) 1605
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Publication History

Received: 12 November 2025

Accepted: 14 January 2026

Accepted Manuscript online:
16 January 2026

Article published online:
29 January 2026