Transcatheter Edge-to-Edge Repair (TEER)

What is transcatheter edge-to-edge repair (TEER)?

Transcatheter edge-to-edge repair (TEER) is a minimally invasive, catheter-based procedure used to treat mitral regurgitation (MR) — a common heart valve disease where the mitral valve fails to close properly, allowing blood to leak backwards into the left atrium.

Traditionally, severe MR is treated through open-heart surgery to repair or replace the mitral valve. However, for patients who are not suitable candidates due to age or medical conditions — such as reduced heart function, kidney impairment, previous stroke, or cancer — TEER provides a safer, less invasive alternative.

How it works

During the TEER procedure, a catheter is inserted through a small needle puncture in the femoral vein in the leg and guided to the heart. Using real-time echocardiography and X-ray guidance, a small clip-like device is positioned across the leaky mitral valve. This device grasps and holds together the valve leaflets at the site of leakage, enabling the valve to close more effectively and reducing the regurgitation.

The procedure is typically done under general anesthesia and allows patients to recover more quickly compared to open-heart surgery.

Types of TEER Devices

Several devices have been developed for TEER procedures, but two systems are most used and currently available in Singapore:

MitraClip (Abbott)

• The MitraClip system was the first commercially available TEER device and has been used in clinical practice for over a decade. It features a mechanical clip that grasps the mitral valve leaflets and has a solid track record in reducing MR in high-risk patients.

PASCAL Precision System (Edwards Lifesciences)

• The PASCAL system is a newer, advanced TEER device that offers several design innovations:
  • A flexible and highly maneuverable delivery system, making it easier to navigate complex heart anatomies
  • A central spacer that fills the gap between mitral leaflets, improving coaptation and reducing stress on the leaflets
  • Independent leaflet grasping and elongation capability, which allow for safer deployment and the ability to disentangle from delicate heart structures if needed

Both systems are approved for use in Singapore, with the PASCAL system now available in select centers including Mount Elizabeth Hospital at Orchard — the earliest private hospital in Southeast Asia to offer it.

Differences between MitraClip and PASCAL Precision System

Both MitraClip and PASCAL are effective devices used in TEER, and each has unique design features that can benefit different patient needs.

• MitraClip may be preferred when the valve structure is suitable for a more straightforward clip application, especially in cases where long-term data and clinical familiarity are prioritized.

• PASCAL may be considered in patients with more complex valve anatomy, or when additional flexibility and navigation within the heart are needed. Its unique features may provide added precision and safety in these cases.

Ultimately, the choice of device is made by the heart team — including cardiologists and imaging specialists — who will assess which option offers the best fit and best outcome for each individual patient. Both devices are valuable tools that help deliver life-changing improvements in patients with MR.

Why do you need transcatheter edge-to-edge repair (TEER)?

TEER may be recommended if you have:

• Severe mitral regurgitation (MR) that causes symptoms or impairs your quality of life
• High or prohibitive surgical risk due to age or existing medical conditions
• Degenerative MR (caused by structural problems in the valve)
• Functional MR (caused by enlargement or dysfunction of the heart muscle)

TEER can significantly reduce mitral leakage, improve symptoms, lower the frequency of hospitalisation, and extend life expectancy in eligible patients.

What are the risks and complications of transcatheter edge-to-edge repair (TEER)?

TEER is generally safe, but as with any heart procedure, there are potential risks. These may include:

• Bleeding or bruising at the catheter insertion site
• Device-related issues, such as misplacement or single leaflet attachment
• Infection
• Residual or recurrent MR
• Stroke (though rare)
• Injury to the mitral valve or surrounding heart structures

The risk of complications may vary depending on individual anatomy and underlying medical conditions.

How do you prepare for transcatheter edge-to-edge repair (TEER)?

Before undergoing TEER, your cardiologist will guide you through a thorough evaluation, which may include:

• Echocardiography (including transoesophageal echocardiogram)
• Cardiac catheterisation
• Blood tests and other scans
• Medication review
• Assessment by a multidisciplinary heart team

You may be advised to fast on the day of the procedure and temporarily stop certain medications (e.g. blood thinners) under medical supervision.

What can you expect during transcatheter edge-to-edge repair (TEER)?

Estimated duration
TEER usually takes 2 – 4 hours, depending on valve anatomy and complexity.

Before the procedure

• You will be admitted to the hospital on the day of, or a day before, your procedure.
• A general anaesthetic will be administered.
• Monitoring lines and imaging equipment will be set up.
• Transesophageal imaging and guidance will be used.

During the procedure

• A catheter is inserted through the femoral vein in your leg.
• Using imaging guidance, the TEER device is positioned at the leaking segment of your mitral valve.
• Once in place, the device clasps the valve leaflets together to reduce regurgitation.
• The device is checked for position and function before being released.

After the procedure

• You will be moved to a recovery area or monitored in a high-dependency unit.
• Most patients can expect 2 – 3 days of hospital stay.
• Mild discomfort or groin soreness is common but usually short-lived.
• Your medical team will perform follow-up echocardiograms and checks before discharge.

Care and recovery after TEER

Most patients return to normal activities within 1 – 2 weeks, though complete recovery may take up to 6 – 8 weeks, especially if you had underlying heart failure or other health issues.

Recovery tips

• Avoid heavy lifting or strenuous activity for the first few weeks.
• Follow your prescribed medications carefully, including blood thinners or antiplatelet agents.
• Attend follow-up appointments for echocardiograms and review of valve function.
• Maintain a heart-healthy lifestyle — diet, exercise, and smoking cessation as advised.
• Your recovery time and outcomes will depend on:
  • The severity of your MR before the procedure
  • The type of TEER device used and procedural success
  • Your overall heart function and medical condition
  • How closely you follow your post-operative care plan

If you or your loved one has been diagnosed with severe mitral regurgitation and open-heart surgery is not an option, TEER may offer a safe and effective alternative. Speak to your cardiologist to see if this innovative procedure is right for you.