Cost-Effectiveness of Transcatheter Aortic Valve Replacement Compared With Surgical Aortic Valve Replacement in High-Risk Patients With Severe Aortic Stenosis: Results of the PARTNER (Placement of Aortic Transcatheter Valves) Trial (Cohort A)

Study Questions:

What is the cost-effectiveness of transcatheter aortic valve replacement (TAVR) compared with surgical aortic valve replacement (AVR) for patients with severe aortic stenosis and high surgical risk?

Methods:

The investigators performed a formal economic analysis based on cost, quality of life, and survival data collected in the PARTNER A (Placement of Aortic Transcatheter Valves) trial in which patients with severe aortic stenosis and high surgical risk were randomized to TAVR or AVR. Cumulative 12-month costs (assessed from a US societal perspective) and quality-adjusted life-years (QALYs) were compared separately for the transfemoral (TF) and transapical (TA) cohorts.

Results:

Although 12-month costs and QALYs were similar for TAVR and AVR in the overall population, there were important differences when results were stratified by access site. In the TF cohort, total 12-month costs were slightly lower with TAVR, and QALYs were slightly higher such that TF-TAVR was economically dominant compared with AVR in the base case and economically attractive (incremental cost-effectiveness ratio <$50,000/QALY) in 70.9% of bootstrap replicates. In the TA cohort, 12-month costs remained substantially higher with TAVR, whereas QALYs tended to be lower such that TA-TAVR was economically dominated by AVR in the base case, and economically attractive in only 7.1% of replicates.

Conclusions:

The authors concluded that TAVR was an economically attractive strategy compared with AVR for patients suitable for TF access.

Perspective:

This study directly evaluated the incremental cost-effectiveness of TAVR relative to AVR among patients who are acceptable candidates for high-risk surgical AVR. Overall, TAVR and AVR resulted in 12-month costs and QALYs that were sufficiently similar that neither therapy would be clearly preferred over the other on health economic grounds. Economic outcomes differed substantially, however, when the analysis was stratified by TAVR access site. The TF-TAVR approach provided a modest benefit in quality-adjusted life expectancy and slightly reduced costs compared with AVR. As a result, TF-TAVR was found to be economically attractive by generally accepted standards and possibly an economically dominant strategy compared with AVR in these patients. Future studies are indicated to determine whether improved experience and outcomes with TA-TAVR may improve its cost-effectiveness relative to AVR.

Clinical Topics: Cardiac Surgery

Keywords: Markov Chains, Heart Valve Prosthesis, Leucine, Life Expectancy


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