Cost-effectiveness of leadless versus transvenous single-chamber ventricular pacing: a propensity-weighted real-world study in France

Background Leadless pacemakers (LP) have emerged as an alternative to conventional transvenous single-lead ventricular pacemakers (SLP), with expanding indications beyond initially selected patients. This study evaluated the clinical and economic outcomes of LP compared with SLP in eligible patients from a real-world French hospital cohort.Methods We conducted a retrospective, propensity-weighted cost-effectiveness analysis from a hospital-based perspective, including all patients who underwent first LP or SLP implantation between 2016 and 2020 at our center. Patients with contraindications or high risk of device failure or infection were excluded. Four-year costs and life-years were used to estimate the incremental cost-effectiveness ratio (ICER). Cost-effectiveness acceptability curves (CEACs) were derived from the bootstrapped distribution of net monetary benefits. Sensitivity analyses explored cost drivers and robustness.Results A total of 352 patients were included (104 LP, 248 SLP). After weighting, LP was associated with shorter procedure duration (52 vs 80 min; p < 0.001) and hospital stay (3.6 vs 4.3 days; p = 0.007). Major clinical events occurred in 25.2% (LP) vs 33.8% (SLP; p = 0.17). Although implantation costs were higher for LP (€11,344 vs €9,326; p < 0.001), total 4-year costs were comparable (€12,925 vs €11,713; p = 0.13). The survival difference was 0.06 years (p = 0.67), yielding an ICER of €20,387 per life-year gained. Bootstrap analysis indicated a 70% probability of cost-effectiveness at a €35,000 per life-year threshold.Conclusions In both device eligible patients, leadless pacemakers showed favorable procedural and clinical outcomes with comparable long-term costs, supporting their cost-effective use in real-world French hospital practice.