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. 2012 Jul;1(2):145-55.
doi: 10.3978/j.issn.2225-319X.2012.06.12.

Perspective on the cost-effectiveness of transapical aortic valve implantation in high-risk patients: Outcomes of a decision-analytic model

Hemal Gada  1 , Shikhar Agarwal, Thomas H Marwick
Affiliations

Perspective on the cost-effectiveness of transapical aortic valve implantation in high-risk patients: Outcomes of a decision-analytic model

Hemal Gada et al. Ann Cardiothorac Surg. 2012 Jul.

Abstract

Background: The incremental cost-effectiveness of transapical transcatheter aortic valve implantation (TAVI) is ill-defined in high-risk patients where aortic valve replacement (AVR) is an option, and has not been ascertained outside a randomized controlled trial.

Methods: We developed a Markov model to examine the progression of patients between health states, defined as peri- and post-procedural, post-complication, and death. The mean and variance of risks, transition probabilities, utilities and cost of transapical TAVI, high-risk AVR, and medical management were derived from analysis of relevant registries. Outcome and cost were derived from 10,000 simulations. Sensitivity analyses further evaluated the impact of mortality, stroke, and other commonly observed outcomes.

Results: In the reference case, both transapical TAVI and high-risk AVR and TAVI were cost-effective when compared to medical management ($44,384/QALY and $42,637/QALY, respectively). Transapical TAVI failed to meet accepted criteria for incremental cost-effectiveness relative to AVR, which was the dominant strategy. In sensitivity analyses, the mortality rates related to the two strategies, the utilities post-AVR and post-transapical TAVI, and the cost of transapical TAVI, were the main drivers of model outcome.

Conclusion: Transapical TAVI did not satisfy current metrics of incremental cost-effectiveness relative to high-risk AVR in the reference case. However, it may provide net health benefits at acceptable cost in selected high-risk patients among whom AVR is the standard intervention.

Keywords: Aortic valve replacement; aortic stenosis; cost-effectiveness; transcatheter valve.

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Figures

Figure 1
Figure 1
Markov model for comparing medical management, transapical TAVI, and AVR in high-risk patients with severe aortic stenosis. The model allows for variable rates of progression to AVR from transapical TAVI screening. Patients undergoing transapical TAVI or AVR enter a Markov model whereby they may progress to five health states (heart failure, access site complications, other complications, stroke or death). AVR = Aortic valve replacement; TAVI = Transcatheter aortic valve implantation
Figure 2
Figure 2
Survival of the patients in the Monte Carlo simulation. AVR = Aortic valve replacement; TAVI = Transcatheter aortic valve implantation
Figure 3
Figure 3
Scatter plot of incremental cost-effectiveness of transapical TAVI relative to AVR from 10,000 simulations of the decision-analytic model. Ellipse represents 95% confidence interval. Line represents the willingness to pay with slope of $100,000/QALY. In this scatter plot, transapical TAVI is incrementally cost-effective relative to AVR in 47% of simulations. AVR = Aortic valve replacement; TAVI = Transcatheter aortic valve implantation; QALY = Quality-adjusted life years
Figure 4
Figure 4
Two-way sensitivity analysis – Annual mortality post-AVR versus annual mortality post-transapical TAVI. Strategy favored with regards to net health benefit is that noted by the legend. AVR = Aortic valve replacement; TAVI = Transcatheter aortic valve implantation
Figure 5
Figure 5
Two-way sensitivity analysis - Utility post-AVR versus utility post-transapical TAVI. Strategy favored with regards to net health benefit is that noted by the legend. AVR = Aortic valve replacement; Med Mgmt = Medical management; TAVI = Transcatheter aortic valve implantation
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