TAVI versus Surgical Aortic Valve Replacement and Medical Therapy in Patients with Aortic Stenosis: Can We Afford it in Australasia?

Abstract

Objective: Transcatheter aortic valve implantation (TAVI) has emerged as an alternative treatment to aortic valve replacement (AVR) for selected patients with severe aortic stenosis. A systematic reviewwas conducted to analyse the cost-effectiveness of this novel technique within reimbursed healthcare systems. Methods and results: Two reviewers used seven electronic databases from January 2000 to November 2012 to identify relevant cost-effectiveness studies onTAVI versus AVR or medical therapy. The primary endpoints were the incremental cost-effectiveness ratio (ICER) and the probability of cost-effectiveness. Eligible studies included those in which cost-effectiveness data was measured or projected for TAVI and either medical therapy or AVR. All forms of TAVI were included and all retrieved publications were limited to English language. Eight studies were included for quantitative assessment. The ICER for TAVI compared with medical therapy for surgically inoperable patients ranged between US$26,302 and US$61,889 per quality adjusted life year gained (PQG). The probability of TAVI being cost-effective compared to medical therapy ranged between 0.03 and 1.00. ICER values for TAVI in comparison to AVR for high-risk surgical candidates ranged between US$32,000 and US$975,697 PQG. The probability of TAVI being cost-effective in this cohort ranged between 0.116 and 0.709. Conclusions: Based on the accepted Australian ICER threshold of AU $69,900 (US $71,882) PQG, TAVI is potentially justified on medical and economic grounds in comparison to medical therapy for inoperable patients. However, in the high-risk surgical patient cohort, there is currently insufficient evidence to economically justify the use of TAVI in preference to AVR.