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SINCE 1 July, health care professionals can finally offer a minimally invasive treatment to patients presenting with severe mitral regurgitation. The Department of Health’s decision to reimburse transcatheter mitral valve repair (TMVr) means the procedure is now available to a wider range of people who previously could not afford it.
Mitral regurgitation is a common condition affecting over 10 000 Australian adults each year. It occurs when the heart’s mitral valve does not close properly, leading to pulmonary congestion. Symptoms of this condition include breathlessness, orthopnoea, fatigue, and ankle oedema.
Some people with the condition can be referred for open-heart surgery to replace or repair the mitral valve and will have good outcomes. With most open-heart surgeries, patients spend up to 2 weeks in hospital, and need several months to fully recover from the operation.
However, older patients, those deemed as surgically high risk or those who have functional mitral regurgitation are better suited to TMVr, which is a minimally invasive procedure.
Before 1 July 2021, my hospital has been conducting this procedure on a charitable basis where patients don’t pay and the hospital absorbs the full cost of this therapy. We must acknowledge the support of our CEO and the hospital for being at the forefront of this revolutionary procedure prior to reimbursement being finalised. Without this, many patients would have missed out on this therapy, with medical management as their only avenue for treatment. Medical management often alleviates the symptoms of mitral regurgitation but does not repair the mitral valve.
TMVr is a catheter-based procedure allowing the insertion of a miniature peg-like device called a MitraClip. The patient goes under general anaesthesia and a catheter is passed through a small puncture in the groin to access the femoral vein. The MitraClip pinches the leaky part of the mitral valve to significantly reduce the degree of mitral regurgitation. The whole procedure is guided via transoesophageal echocardiogram and usually takes no longer than 2 hours. Patients usually recover quickly and can be sent home within days. A TMVr procedure is not for everyone, but it is a great alternative for people who are deemed unfit for open-heart surgery.
This treatment option allows patients to be up and about within a day of the procedure, with many experiencing an immediate improvement in their symptoms. After a month, many report significant improvements in their exercise tolerance and their day-to-day activities.
The COAPT trial was an important multicentre, randomised controlled trial of TMVr and medical therapy versus medical therapy alone in symptomatic patients with heart failure and moderate to severe or severe mitral regurgitation. The results were compelling; the number of people needed to treat (NNT) with TMVr to prevent one heart failure hospitalisation at 24 months was 3.1. To save one life, the NNT with TMVr at 24 months was 5.9. Both of these results were better than average NNTs such as statins and blood pressure medicines.
One of our recent patients, aged in their 70s, could no longer work their own agricultural business because of breathlessness, until they had the TMVr procedure done. Now they have gone back to doing what they love and are no longer symptomatic. Seeing profound impacts on people’s lives like this is always humbling.
Reimbursement of TMVr has been years in the making and is welcomed by the interventional cardiology community. Over time, a person with severe symptomatic mitral regurgitation can develop heart failure if they are left untreated, and their prognosis worsens. Depending on some factors, their life expectancy can be just 2–3 years. Once the heart has started to fail, we have almost missed the boat for treatment, so it is important to act quickly.
We are concerned about the patients who never make it to us. They may have been seeing a primary care physician who detects a murmur, but they are deemed too elderly for any interventions. What these physicians do not realise is that we can perform minimally invasive procedures on some of these individuals, despite their age. And most importantly, we can restore their quality of life and reduce their symptoms and their burden to the health care system.
Now that TMVr is reimbursed, I hope primary care physicians will become more aware of this treatment option, and that people who have not been referred in the past will be able to access treatment. Education on mitral regurgitation and the treatment solutions must be targeted at primary care physicians who are not looking after these types of patients regularly.
My message to them is: if someone has a murmur, please send them off to get assessed by your local cardiologist because you never know what it is, how severe it is and what the treatment options are until they have been assessed. Don’t write off a patient simply because you think they are too old.
Awareness of the patients well suited to this minimally invasive procedure should also be raised among our cardiologist colleagues. This education can take place within our own hospitals and through case study presentations at larger meetings. For cardiologists based more regionally and rurally, webinars can be set up for remote educational activities.
As an interventional cardiologist who is passionate about helping patients who have this complex structural heart disease, I am thrilled to see that the government has approved reimbursement for this procedure. It is going to help many patients that we previously had trouble treating because of funding restrictions. The clinical evidence is all there, and now that the funding has caught up with it, a big hurdle has been removed.
Dr Dennis Wang, is an interventional and cardiac imaging cardiologist located at the Sydney Adventist, Gosford Private, and North Shore Private Hospitals.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.