Cost-Effectiveness and Projected Survival of Self-Expanding Transcatheter Versus Surgical Aortic Valve Replacement for High Risk Patients in a European Setting: A Dutch Analysis Based on the CoreValve High Risk Trial

Background: Clinical and economic outcomes of self-expanding bioprosthetic transcatheter aortic valve implantation (TAVI) in high-risk surgical candidates are unknown in the European setting. The objective of this study was to project life expectancy and to estimate the cost-effectiveness of TAVI in a European setting.
Methods: Cost-utility analysis via probabilistic Markov modeling was performed. A simulated cohort of 83-year-old men and women (53 and 47%, respectively) with severe aortic stenosis at high but not extreme surgical risk were observed in the CoreValve High Risk Trial. Costs were based on resource use data from a Dutch academic medical center and costing guidelines. Undiscounted life expectancy and discounted costs, quality-adjusted life years (QALYs), incremental cost-effectiveness ratio (ICER), and proportion cost-effective at a willingness-to-pay threshold of €50,000/QALY were evaluated. Beyond the base case, further analyses explored a “lean scenario” that considered a shorter TAVI procedure time and hospital stay. Results: Mean projected survival increased by 0.65 life years (5.62 for TAVI vs. 4.97 for SAVR). TAVI was projected to add 0.41 (3.69 vs. 3.27) QALYs at an increased cost of €9048 (€51,068 vs. €42,020), resulting in an ICER of €21,946 per QALY gained. The probability of TAVI being cost-effective was 71%. Further cost reduction of approximately €5400 in addition to the “lean” assumptions would make TAVI the dominant strategy. Conclusion: A self-expanding TAVI system for high-risk surgical candidates increases quality-adjusted life expectancy at an economically acceptable cost in the Dutch setting. Reductions in procedure time and length of hospital stay will further improve the value of TAVI.