Response to: Correspondence on 'Cost-effectiveness of transcatheter edge-to-edge repair in secondary mitral regurgitation does need confirmation' by Armoiry and Connock

We read with interest the response of Armoiry and Connock to our editorial and to the Cohen et al paper it referred to. This response demonstrates the wide interest on costeffectiveness of transcatheter edgetoedge repair (TEER) in secondary mitral regurgitation. Armoiry and Connock generously conclude that the paper by Cohen et al ‘represents a valuable contribution’, although criticising it throughout the text. Regarding our editorial, we are sorry that Armoiry and Connock disagree with our statement that costeffectiveness of TEER in secondary mitral regurgitation does not need confirmation. Yet, our statement refers strictly to the UK NHS and is underpinned by the costeffectiveness analyses that informed the National Institute for Health and Care Excellence (NICE) guidelines recommendation: the NICE MitraClip model and Shore 2020. Although Armoiry and Connock state that in the UK ‘costeffectiveness is a key criterion to judge recommendation’ and although at current device cost, in the UK NHS, the incremental cost per qualityadjusted lifeyear (QALY) gained for TEER in secondary mitral regurgitation was significantly above the £20 000 threshold in both NICE analysis and Shore 2020, the NICE guidelines do recommend TEER in secondary mitral regurgitation; the recommendation (‘consider TEER’) is of similar strength with the European and American guidelines recommendation (class II). The NICE incremental cost per QALY gained threshold refers to a strong recommendation (‘offer TEER’), equivalent with a European and American recommendation class I. However, the existent clinical effectiveness evidence prevents all guidelines from making a strong recommendation. Further costeffectiveness confirmation would only be needed in case of new clinical effectiveness evidence supportive of a strong recommendation and of reduction of device cost in the UK NHS.