• mitral valve insufficiency
• delivery of health care
• health care economics and organisations
• heart failure
• systolic

Transcatheter edge-to-edge repair (TEER) may be considered in inoperable patients with severe mitral regurgitation secondary to left ventricular systolic dysfunction, who remain symptomatic despite optimal heart failure guideline-directed medical therapy including cardiac resynchronisation therapy when appropriate. All current guidelines agree in this regard. The European (ESC/EACTS) and American (ACC/AHA) professional societies guidelines define the recommendation for TEER as class IIa with level of evidence B. The UK National Institute for Heath and Care Excellence (NICE) guidelines recommend ‘consider TEER’, which is the NICE equivalent of a class II indication, by comparison with a class I indication that would have been worded as ‘offer TEER’. The weak recommendation in all guidelines reflects the uncertainty of the clinical evidence, with one randomised control trial (COAPT)1 finding symptomatic and prognostic benefit in heart failure patients with reduced left ventricular systolic function and severe secondary mitral regurgitation and one randomised control trial (MITRA-FR)2 finding no benefit. Several attempts of explaining this discrepancy were made. The generally accepted explanation is that TEER can be of benefit if the mitral regurgitation rather than the left ventricular systolic dysfunction drives the heart failure symptoms and the guidelines recommendation refers strictly to this clinical scenario.

In the UK, the introduction and use in clinical practice of novel technologies or new indications for existent technologies are regulated by NICE Technology Appraisals, NHS England Commissioning through Evaluation (CtE) supported by NICE, NHS England Clinical Commissioning Policy and Clinical Guidelines developed by NICE. Currently, TEER is commissioned by NHS England only for primary mitral regurgitation, based on the CtE study performed3 before the development of the first NICE clinical guidelines on heart valve disease.4 However, the recently published NICE clinical guidelines recommend TEER for secondary mitral regurgitation as well. Furthermore, as part of the development process of …