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The publication by Guler et al. [1] highlights a very problematic area in valvular surgery, the treatment of paravalvular leakage (PVL). They successfully treated mitral PVL transapically in a highrisk patient with an Amplatzer duct occluder device. They avoided all the known complications of redo surgery and the additional risks that might be brought by the comorbidities of the patient. The relation of the PVL with the hinge points of the prosthetic valve was very well emphasized, which is one of the most important determinants of procedural success rates. They also used three-dimensional transoesophageal echocardiography and demonstrated the procedure with excellent pictures. In this valuable report, there is a particular topic we would like to discuss. We know that mitral PVL has a detrimental course, especially compared with aortic PVL (16 ± 8 vs 70 ± 12% event-free survival rates in 8 years) [2]. This finding mandates immediate therapeutic intervention. In percutenous modalities of PVL occlusion, there is no real rim-like atrial septum. The anatomy may increase the tendency for residual leakages after the first occluder deployment. In addition, this strategy, particularly in the aortic position, may cause a new PVL in the anterior or posterior aspect of the device, which may require a second or third occluder implantation and even embolization after first occluder implantation. Therefore, the size of the connector that connects both discs should be of the same diameter as the defect. Sriratanaviriyakul et al. [3] reported a similar case in which they had to implant a second occluder device. So, it should be emphasized that, due to anatomical features, size matters in occluder device treatment of PVLs to prevent secondary leakages and possible embolization. Because, as the number of implanted occluder devices increase due to unfavorable anatomy, the risk of embolization will also increase. Embolized occluder devices, even in simple secundum atrial septal defects, increase the mortality 20-fold compared with elective surgery [4]. In conclusion, we believe that interventional treatment modalities of PVL will save patients’ lives with decreased adverse event rates. We would like to congratulate the authors for their success and thank them for sharing their experience with the readers.

Does the anatomy of mitral paravalvular leakage increase the risk of device embolization in percutenous treatment modalities?