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We read with interest the prospective multicentre registry by Albenque et al reporting medium-term outcomes and prognostic factors after transcatheter paravalvular leak (PVL) closure1. The authors should be acknowledged for providing one of the few prospective datasets with a 2-year follow-up in this challenging patient population. Their finding that early clinical success at one month is the strongest predictor of adverse outcomes is clinically relevant and consistent with prior observational data23. However, several methodological aspects merit further clarification.
First, the definitions of technical and clinical success deviate in part from the Academic Research Consortium (ARC) and ARC-aligned frameworks commonly used in contemporary structural heart studies23. The use of standardised endpoint definitions would improve comparability across registries and enhance external validity. In addition, the absence of a surgical comparator arm limits the interpretation of outcomes in the context of current evidence, suggesting comparable long-term survival but higher early mortality with redo-surgery34. Even a non-randomised, propensity-adjusted comparison could have provided additional clinical perspective.
Second, patient selection criteria for transcatheter versus surgical PVL closure are not fully detailed. Although decisions were made by local Heart Teams, the lack of explicit, harmonised criteria across centres introduces potential intercentre variability. Prior studies have shown that parameters such as extent of dehiscence, circumferential involvement, and proximity to the sewing ring critically influence the choice of therapy345. Clear reporting of these criteria would strengthen the reproducibility and generalisability of the authors' registry findings.
Third, more granular echocardiographic characterisation would add substantial value. The number of PVLs per patient, their individual grades, morphology, and cumulative burden were not fully reported. This is clinically relevant, as multiple or complex PVLs have been associated with worse haemolysis and higher rehospitalisation rates5. Moreover, established echocardiographic predictors such as mitral annular calcification and prior infective endocarditis – previously linked to reduced clinical success and survival – were not analysed and could potentially refine risk stratification34.
Lastly, issues related to residual and recurrent PVL deserve further attention. It remains unclear whether follow-up imaging was performed systematically in all patients or only in those who were symptomatic and what proportion of patients lacked routine echocardiographic reassessment. The absence of data on recurrent PVL, as well as on patients with prior transcatheter aortic valve implantation or mitral valve replacement, represents an important limitation given the evolving landscape of prosthetic valve interventions567. Addressing these points in future analyses or supplementary data would further enhance the clinical impact of this important registry.
Conflict of interest statement
The authors have no conflicts of interest to declare.
