Are Transcatheter Aortic Valve Implantations Cost-Effective in the Management of Patients With Aortic Stenosis?

Abstract

The initial short-term outcomes of transcatheter aortic valve implantation (TAVI) have been positive with recent data from the Placement of Aortic Transcatheter Valve (PARTNER) cohort A trial, demonstrating that TAVI was not inferior to open aortic valve replacement (AVR) with regard to all-cause mortality at one year [1National Institute for Health and Clinical Excellence (NICE)Transcatheter aortic-valve implantation for aortic stenosis.http://guidance.nice.org.uk/IPG266Date: 2011Google Scholar, 2Smith C.R. Leon M.B. Mack M.J. et al.Transcatheter versus surgical aortic-valve replacement in high-risk patients.N Engl J Med. 2011; 364: 2187-2198Crossref PubMed Scopus (4437) Google Scholar]. However, long-term data are awaited and, consequently, TAVI is reserved for high-risk elderly patients who are assessed on a case-by-case basis [1National Institute for Health and Clinical Excellence (NICE)Transcatheter aortic-valve implantation for aortic stenosis.http://guidance.nice.org.uk/IPG266Date: 2011Google Scholar, 2Smith C.R. Leon M.B. Mack M.J. et al.Transcatheter versus surgical aortic-valve replacement in high-risk patients.N Engl J Med. 2011; 364: 2187-2198Crossref PubMed Scopus (4437) Google Scholar]. Historically, cardiac interventions place more emphasis on clinical outcome rather than cost effectiveness. Despite an extensive literature search, there are only limited data describing cost comparisons of TAVI with open AVR. The PARTNER cohort B trial did evaluate cost effectiveness and determined the cost of performing TAVI to be $78,540 (£48,404; €54,747) with a life expectancy gain of 0.7 to 1.9 years over medically managed patients, equating to $61,889 (£38,142; €43,140) per quality adjusted life year [3O'Riordan M. TAVI cost-effective treatment in surgery ineligible patients: PARTNER cohort B cost analysis.http://www.theheart.org/article/1205025.doGoogle Scholar]. In order to make a basic objective cost-comparative assessment of TAVI, local financial costings were obtained from The Department of Health, Social Services, and Public Safety Northern Ireland. The average total cost at our unit of an open AVR was $20,337 (£12,534; €14,746) and the average total cost of TAVI was $31,316 (£19,300; €22,706). While TAVI was approximately 50% more expensive than traditional AVR, we would propose that there is a significant cost saving in improving symptomatology among high-risk inoperable patients and, hence, hospitalization periods. Indeed, the PARTNER cohort B trial demonstrated a $23,372 (£14,404; €16,292) higher cost for medically managed patients over TAVI patients in the first year [3O'Riordan M. TAVI cost-effective treatment in surgery ineligible patients: PARTNER cohort B cost analysis.http://www.theheart.org/article/1205025.doGoogle Scholar]. However, it is important to be aware that these studies related to high-risk patients who were deemed unsuitable for surgery and consequently TAVI cannot be considered transferable at this stage to the wider population with aortic stenosis. Although some authors have acknowledged this, there appears to be a growing willingness to assess an expanded role for TAVI among high-risk patients who are surgical candidates and also low-risk patients with aortic stenosis [2Smith C.R. Leon M.B. Mack M.J. et al.Transcatheter versus surgical aortic-valve replacement in high-risk patients.N Engl J Med. 2011; 364: 2187-2198Crossref PubMed Scopus (4437) Google Scholar, 4Leon M.B. Smith C.R. Mack M. et al.Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery.N Eng J Med. 2010; 363: 1597-1607Crossref PubMed Scopus (5084) Google Scholar]. Longer term outcome data should be awaited prior to this discussion and we would suggest that careful cost analysis should be included in the eventual evaluation of TAVI when assessing its use among other population groups as our data indicated a significantly higher cost with TAVI usage.