Jonathan Byrne, consultant cardiologist at King’s College Hospital (London, UK) and UK lead of the Valve for Life programme, an initiative that aims to improve and expand access to transcatheter therapies for heart valve disease, discusses the current availability of transcatheter mitral valve repair procedures in the UK.
Transcatheter edge-to-edge repair (TEER) has become a well-established, minimally invasive treatment option for patients with mitral regurgitation (MR) worldwide and the mitral valve clip—MitraClip (Abbott)—has become a popular and widely used device since its introduction.
Currently, the NHS commissioning decision recommends treatment with TEER for patients with degenerative mitral valve disease (DMVD), characterised by the progressive deterioration and structural compromise of the mitral valve leaflets. This policy excludes individuals with functional mitral regurgitation (FMR), which is typically secondary to myocardial infarction, atrial fibrillation, or cardiomyopathy, where the regurgitation arises from left ventricular remodelling and altered mitral annulus geometry rather than primary leaflet pathology.
The treatment pathway for FMR typically begins with medical management aimed at optimising heart failure therapy and controlling contributing factors such as atrial fibrillation. The majority of patients are unsuitable for surgery, and TEER has emerged as a minimally invasive alternative for some. In this group, TEER can lead to improved quality of life (QoL) with an improvement in symptoms such as breathlessness and oedema, and a lower mortality.
Patients with FMR are often not suitable for cardiac surgery, and pharmacological treatments provide limited symptom relief. These individuals frequently experience recurrent symptoms, leading to repeated visits to their general practitioners and frequent admissions to emergency departments, significantly impacting their quality of life and health are resource utilisation.
In certain cases, patients can be considered for compassionate treatment with TEER or special case reviews, which involve multidisciplinary team evaluations and extensive paperwork. These processes can be protracted, often taking several weeks to coordinate and finalise, further delaying potential interventions.
TEER in the UK
TEER has been slow to take off in the UK. Data have shown that the UK lags behind many of its continental neighbours when it comes to adoption. Data suggest that the total number of TEER procedures in the UK over the last three years could be upwards of 2,000, assuming full capacity operations in 2022 and 2023 and a similar or growing number from 2021.1
NHS England approved the routine commissioning of mitral TEER in 2019. The decision marked the end of a funding battle that lasted almost a decade, with initial National Institute for Health and Care Excellence (NICE) guidance published in 2011.
Over 23 centres across the UK are active and could achieve similar procedure rates to other European countries if both DMR and FMR were commissioned. Each centre performs 50–100 procedures each year based on capacity.
The future of TEER
This year in May 2024, the NHS England Clinical Priorities Advisory Group (CPAG) made recommendations on proposed clinical commissioning policy proposals to the NHSE Board. The timeline for signoff is not definitive however, it is expected that the outcome of the CPAG process will be published in the coming months.
It is hoped that comprehensive commissioning will align the UK with its European counterparts, providing better access to care for patients and ensuring the number of referrals for the procedure matches its availability and helping to eliminate geographical disparities in service provision.
Widespread commissioning of TEER better equips the NHS to manage the growing burden of heart valve disease and deliver an improved standard of care for patients with mitral valve disease, both now and in the future.
