Catheterization and Cardiovascular Interventions 85:1106–1107 (2015)

Letter to the Editor Rebuttal: Percutaneous Paravalvular Leak Closure After TAVI: Not-So-Demanding TO THE EDITOR

We read with interest the letter written by Vavuranakis et al. and are pleased to have the chance to reply to his letter. Dr. Vavuranakis et al. have added a great deal to the literature for how to deal with malposition of CoreValve (Medtronic, Minneapolis, MN), [1–3] which has helped decrease the amount of aortic regurgitation. In response to their point of emergency situations, we agree with their point that the bailout strategies of TAVI-in-TAVI, snare, remove-and-reposition, and balloon repositioning techniques should be tried. Paravalvular leak closure in the acute setting after TAVI is not recommended. As mentioned in their letter, all of the cases in our paper were chronic cases of aortic insufficiency. Second, the authors bring an interesting point about the differential height of the pericardial skirt along the circumference of the prosthesis. They mention that this varies widely between 12 and 32 mm. According to their response, if there is initial failure to cross the struts, this may be due to the pericardial skirt rising up toward the inflow tract. However, this is not usually the case with high crossing. The overall strut coverage at the immediate inflow tract is only a fraction of the overall circumference at that level. A reference image of three valve sizes can be found online [4]. In fact, crossing the struts has never been a problem in our experience and we are surprised to hear, that there were difficulties in doing so. The concern of proximal closure disc-related valvular obstruction is an interesting one. The authors mention that a low access point may cause the elongated plug to be partly inside the struts—however, all the currently available plugs are not long enough to be able to do that if the distal portion of the closure device (ventricular side) is on the other side of the annulus—where it has to be to close the hole. However, the overall reason for a high crossing is a simpler C 2014 Wiley Periodicals, Inc. V

one—the high cross allows the ability to steer the catheter downwards to cross the leak. The friction between the catheter and the strut at a more lower angle is the reason why the valve should be crossed at a high crossing point. As for the theoretical risk of valve dislodgement during paravalvular leak closure procedures, this has not been an issue in our series. We attribute this to the presence of a calcific aortic valve, strong outward force of the nitinol struts, careful sizing, gentle maneuvering when possible and mainly to our strategy of waiting at least several months until we attempt to close the leak. Sameer Gafoor, MD, Kerstin Piayda, BA, Simon Lam, MD, Stefan Bertog, MD, Laura Vaskelyte, MD, Ilona Hofmann, MD, Horst Sievert, MD* Department of Cardiology, Cardiovascular Center Frankfurt, Frankfurt, Germany Jennifer Franke, MD Department of Cardiology, University of Heidelberg, Heidelberg, Germany Stefan Bertog, MD Department of Cardiology, Minneapolis Veterans Affairs Hospital, Minneapolis, Minnesota

Conflict of interest: The authors’ institution has ownership interest in or has received consulting fees, travel expenses, or study honoraries from the following companies: Abbott, Access Closure, AGA, Angiomed, Arstasis, Atritech, Atrium, Avinger, Bard, Boston Scientific, Bridgepoint, Cardiac Dimensions, CardioKinetix, CardioMEMS, Coherex, Contego, CSI, EndoCross, EndoTex, Epitek, Evalve, ev3, FlowCardia, Gore, Guidant, Guided Delivery Systems, Inc., InSeal Medical, Lumen Biomedical, HLT, Kensey Nash, Kyoto Medical, Lifetech, Lutonix, Medinol, Medtronic, NDC, NMT, OAS, Occlutech, Osprey, Ovalis, Pathway, PendraCare, Percardia, pfm Medical, Rox Medical, Sadra, SJM, Sorin, Spectranetics, SquareOne, Trireme, Trivascular, Velocimed, Veryan. *Correspondence to: Prof. Dr. Horst Sievert, MD; CardioVascular Center Frankfurt, Seckbacher Landstrasse 65, Frankfurt am Main, Germany E-mail: [email protected] Received 24 August 2014; Revision accepted 25 August 2014 DOI: 10.1002/ccd.25654 Published online 5 September 2014 in Wiley Online Library (wileyonlinelibrary.com)

Rebuttal: Percutaneous Paravalvular Leak Closure After TAVI

REFERENCES 1. Vavuranakis M, Vrachatis DA, Toutouzas KP, Chrysohoou C and Stefanadis C. "Bail out" procedures for malpositioning of aortic valve prosthesis (CoreValve). Int J Cardiol 2010;145:154–155. 2. Vavuranakis M, Kariori M, Vrachatis D, et al. "Balloon withdrawal technique" to correct prosthesis malposition and treat paravalvular aortic regurgitation during TAVI. J Invasive Cardiol 2013;25:196–197.

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3. Vavuranakis M, Vrachatis D and Stefanadis C. CoreValve aortic bioprosthesis: Repositioning techniques. JACC Cardiovasc Interv 2010;3:565; author reply 566. 4. Husten, L. FDA grants approval earlier than expected for Medtronic’s corevalve. January 17, 2014. Available at: http://www. forbes.com/sites/larryhusten/2014/01/17/fda-grants-earlier-thanexpected-approval-for-medtronics-corevalve/ accessed on August 11, 2014.

Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).

Rebuttal: percutaneous paravalvular leak closure after TAVI: not-so-demanding.

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