Cost-effectiveness of transcatheter valvular interventions: economic challenges

The unsustainable trend of rising healthcare costs necessitates difficult allocation decisions by governments, policymakers, and physicians. Consequently, recent advances in transcatheter valve therapies require not only clinical evaluation, but also careful economic evaluation. Under current indications, each year there are nearly 18,000 new candidates for transcatheter aortic valve implantation (TAVI) in European countries and an additional 9,200 in North America, with an estimated cost of more than $2 billion per year. Nonetheless, when compared with standard medical therapy for severe aortic stenosis (AS), TAVI leads to gains in life expectancy at an incremental cost that is acceptable by most Western standards. On the other hand, for high-risk (but operable) patients with severe AS, TAVI provides no proven survival advantage and only a transient quality of life benefit compared with surgical aortic valve replacement (SAVR). Thus, for these patients, the cost-effectiveness of TAVI compared with SAVR hinges on the magnitude and duration of the quality of life benefit as well as the relative cost of both procedures. Current data suggest that, for patients who are eligible for transfemoral access, TAVI is economically attractive (or even economically dominant) compared with high-risk SAVR. However, the cost-effectiveness of TAVI for patients who are not suitable for a transfemoral approach appears to be less favourable. Transcatheter mitral valve repair is in an earlier stage of clinical implementation than TAVI. As the evidence for this procedure accumulates, more formal economic analysis should be feasible.