Cost-Effectiveness of LA Appendage Closure Device
How does the cost of left atrial appendage (LAA) closure compare with that of various oral anticoagulants (OACs) in patients with nonvalvular atrial fibrillation (AF)?
Registry data from two English centers (n = 110 patients with AF; mean age = 71 years; mean CHADS2 = 2.8, CHA2DS2-VASc = 4.5, and HAS-BLED = 3.8) performing LAA closure with the Watchman device were prospectively collected. Outcomes also were compared with those of patients in randomized trials evaluating various pharmacologic stroke prevention strategies. The cost impact model was based on the United Kingdom National Health Service with a 10-year time horizon.
Acute procedural success in implanting the LAA closure device was >90%. One patient developed pericardial tamponade requiring percutaneous drainage. At 6 months, almost 90% of patients were taking only aspirin (as opposed to warfarin or dual antiplatelet therapy). The annual rates for overall mortality, stroke, and bleeding were 1.8%, 0.9%, and 0.9%, respectively. Based on the mean CHA2DS2-VASc score of this cohort, the expected annual stroke rate (in the absence of OAC) would be 6.3%. The expected annual bleeding rate would be (on warfarin therapy) 7.6%. The time required for LAA closure device to achieve cost parity with various OACs ranged from 5 years (for rivaroxaban) to 8.4 years (for warfarin). At 10 years, LAA closure was cost-effective against all strategies. On subgroup analysis, LAA closure was less likely to be cost-effective versus OAC medications in patients with a CHA2DS2-VASc score ≤3.
This study confirms the effectiveness of LAA closure devices in reduction of stroke and hemorrhage. Modeling data also suggest that the closure device studied achieves cost parity against various comparators, especially in patients with high-risk features.
The Watchman device is currently approved for patients with nonvalvular AF who are at risk for stroke, and who prefer not to take long-term OAC. The complication rates during implantation have continued to decrease, and further refinements to the device are being made. The current and other larger multicenter studies have shown an improvement in long-term outcomes in patients undergoing implantation of LAA closure devices. The economic data presented in this study are encouraging as well. An important caveat is that the cost parity data are sensitive to the stroke rates associated with the closure device. In other words, higher stroke rates may diminish the cost-effectiveness of the closure device.
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