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.