Enhancing success rate in transcatheter closure of paravalvular leaks post-TAVI with vascular plug technology

This commentary refers to ‘Treatment of late paravalvular regurgitation after transcatheter aortic valve implantation: prognostic implications’, by U. Landes et al., https://doi.org/10.1093/eurheartj/ehad146 and the discussion piece ‘Post-Transcatheter Aortic Valve Implantation paravalvular leak: multiple aetiologies and no panacea’, by E. Harari and U. Landes, https://doi.org/10.1093/eurheartj/ehad696. We read with interest the study by Landes et al.1 on the efficacy and safety of different transcatheter options [redo transcatheter aortic valve implantation (TAVI), plug closure, and valvuloplasty post-TAVI] in reducing moderate or greater paravalvular leaks (PVLs) after the index TAVI using data from the redo-TAVI registry. Despite advancements in the TAVI procedure, including new generation devices, post-TAVI PVL still occurs with an incidence of <5%.2 More than mild post-TAVI PVL has been associated with unfavourable clinical outcomes, even in asymptomatic individuals. In fact, moderate or greater PVL has been linked to a two-fold increase in all-cause mortality, heart failure hospitalizations, and the need for re-intervention.3 It is well established that addressing PVL through plug insertion is more challenging in TAVIs than in surgical valves.4 The redo-TAVI registry documented plug-based treatment attempts in 79 patients, resulting in a modest success rate of 52.4%. In contrast, our PLUGinTAVI Registry observed a success rate of 94% (n = 45) for PVL closure with plugs, although success definitions varied slightly among registries.5 Plausible factors contributing to our registry’s higher procedural success rate include the use of specific procedural strategies like mother and child techniques in one-third of patients and arterio-arterial loops in 25% of cases. These techniques are particularly useful in this setting due to the generally challenging progression of delivery catheters through the TAVI struts. Furthermore, our registry demonstrated a higher utilization rate of lower profile AVP-III and AVP-IV devices, which are preferred for small leaks commonly encountered post-TAVI. These devices can be delivered via 5F, 6F, or even 4F diagnostic catheters, reducing the need for exchanging larger catheters and sheaths and minimizing excessive manipulation. The potential clinical benefit of aortic PVL closure is directly proportional to the extent of PVL reduction achieved.1,5 In the Redo-TAVI registry, patients with residual moderate or greater PVL despite re-intervention had higher mortality at 1 year compared with patients in whom aortic regurgitation (AR) was reduced to mild or less (21% vs. 8%, respectively). These findings align with the clinical outcomes observed in our PLUGinTAVI Registry, where a sustained reduction in AR post-TAVI PVL closure led to improved New York Heart Association functional status and a high survival rate of 85% during long-term follow-up. In contemporary clinical practice, an increasing number of low-risk and intermediate-risk patients with a limited number of comorbidities and severe aortic stenosis are undergoing TAVI treatment. Therefore, we commend the authors for their work, as it is crucial to gather evidence regarding treatment options for post-TAVI leaks and their long-term effects. All authors declare no conflict of interest for this contribution.