Cost-Effectiveness of Left Atrial Appendage Closure for Stroke Reduction in Atrial Fibrillation: Analysis of Pooled, 5-Year, Long-Term Data

Abstract

Background Recent publications reached conflicting conclusions about the cost-effectiveness of left atrial appendage closure (LAAC) with the Watchman device (Boston Scientific, Marlborough, MA) for stroke risk reduction in nonvalvular atrial fibrillation (AF). This analysis sought to assess the cost-effectiveness of LAAC relative to both warfarin and nonwarfarin oral anticoagulants (NOACs) using pooled, long-term data from the randomized PROTECT AF (Watchman Left Atrial Appendage System for Embolic Protection in Patients With Atrial Fibrillation) and PREVAIL (Prospective Randomized Evaluation of the Watchman LAA Closure Device in Patients With Atrial Fibrillation Versus Long-Term Warfarin) trials. Methods and Results A Markov model was constructed from a US payer perspective with a lifetime (20-year) horizon. LAAC clinical event rates and stroke outcomes were from pooled PROTECT AF and PREVAIL trial 5-year data. Warfarin and NOAC inputs were derived from published meta-analyses. The model was populated with a cohort of 10 000 patients, aged 70 years, at moderate stroke and bleeding risk. Sensitivity analyses were performed. LAAC was cost-effective relative to warfarin by year 7 ($48 674/quality-adjusted life-year) and dominant (more effective and less costly) by year 10. LAAC became cost-effective and dominant compared with NOACs by year 5. Over a lifetime, LAAC provided 0.60 more quality-adjusted life-years than warfarin and 0.29 more than NOACs. In sensitivity analyses, LAAC was cost-effective relative to warfarin and NOACs in 98% and 95% of simulations, respectively. Conclusions Using pooled, 5-year PROTECT AF and PREVAIL trial data, LAAC proved to be not only cost-effective, but cost saving relative to warfarin and NOACs. LAAC with the Watchman device is an economically viable stroke risk reduction strategy for patients with AF seeking an alternative to lifelong anticoagulation.

Keywords: Watchman; anticoagulant; atrial fibrillation; cost‐effectiveness; left atrial appendage closure; nonwarfarin oral anticoagulants.

Figure 1

Model schematic depicting left atrial appendage closure (LAAC) and nonwarfarin oral anticoagulant (NOAC) patient pathways. Patient pathways for LAAC and NOAC.

Figure 2

Cumulative cost curve: left atrial appendage closure (LAAC) vs warfarin vs nonwarfarin oral anticoagulant (NOACs). Cumulative costs by year for LAAC, warfarin, and NOACs.

Figure 3

A, Scatter plots of incremental costs and incremental quality‐adjusted life‐years (QALYs) at 20 years for left atrial appendage closure (LAAC) vs warfarin. Probabilistic sensitivity analysis (PSA) results reflect 5000 model simulations to estimate the effect of uncertainty on model results. B, Scatter plots of incremental costs and incremental QALYs at 20 years for LAAC vs nonwarfarin oral anticoagulants (NOACs). PSA results reflect 5000 model simulations to estimate the effect of uncertainty on model results.