title: Contemporary Costs Associated With Transcatheter Aortic Valve Replacement: A Propensity-Matched Cost Analysis.
abstract: BACKGROUND
  The Placement of Aortic Transcatheter Valve (PARTNER) trial suggested an economic advantage for transcatheter aortic valve replacement (TAVR) for high-risk patients. The purpose of this study was to evaluate the cost effectiveness of TAVR in the "real world" by comparing TAVR with surgical aortic valve replacement (SAVR) in intermediate-risk and high-risk patients.
  
  
  METHODS
  A multiinstitutional database of The Society of Thoracic Surgeons (STS) (2011 to 2013) linked with estimated cost data was evaluated for isolated TAVR and SAVR operations (n = 5,578). TAVR-treated patients (n = 340) were 1:1 propensity matched with SAVR-treated patients (n = 340). Patients undergoing SAVR were further stratified into intermediate-risk (SAVR-IR: predicted risk of mortality [PROM] 4% to 8%) and high-risk (SAVR-HR: PROM >8%) cohorts.
  
  
  RESULTS
  Median STS PROM for TAVR was 6.32% compared with 6.30% for SAVR (SAVR-IR 4.6% and SAVR-HR 12.4%). A transfemoral TAVR approach was most common (61%). Mortality was higher for TAVR (10%) compared with SAVR (6%, p < 0.047), whereas the SAVR group accrued higher major morbidity (27% vs 14%, p < 0.001) and longer postoperative hospital duration (7 days vs 6 days, p < 0.001). Importantly, TAVR incurred twice the median total costs compared with SAVR ($69,921 vs $33,598, p < 0.001). The increased cost of TAVR was largely driven by the cost of the valve (all p < 0.001). Intermediate-risk patients undergoing SAVR demonstrated the most exaggerated cost savings versus TAVR.
  
  
  CONCLUSIONS
  TAVR was associated with greater total costs and mortality compared with SAVR in intermediate-risk and high-risk patients while conferring lower major morbidity and improved resource use. Increased cost of TAVR appears largely related to the cost of the valve. Until the price of TAVR valves decreases, these data suggest that TAVR may not provide the most cost-effective strategy, particularly for intermediate-risk patients.
authors.affiliation: Investigators for the Virginia Cardiac Surgery Quality Initiative; Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia. Electronic address: gorav@virginia.edu.
authors.forename: Gorav
authors.initials: G
authors.lastname: Ailawadi
authors.affiliation: Investigators for the Virginia Cardiac Surgery Quality Initiative; Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia.
authors.forename: Damien J
authors.initials: DJ
authors.lastname: LaPar
authors.affiliation: Investigators for the Virginia Cardiac Surgery Quality Initiative; Department of Cardiothoracic Surgery, Inova Heart and Vascular Center, Falls Church, Virginia.
authors.forename: Alan M
authors.initials: AM
authors.lastname: Speir
authors.affiliation: Investigators for the Virginia Cardiac Surgery Quality Initiative; Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia.
authors.forename: Ravi K
authors.initials: RK
authors.lastname: Ghanta
authors.affiliation: Investigators for the Virginia Cardiac Surgery Quality Initiative; Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia.
authors.forename: Leora T
authors.initials: LT
authors.lastname: Yarboro
authors.affiliation: Investigators for the Virginia Cardiac Surgery Quality Initiative; Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia.
authors.forename: Ivan K
authors.initials: IK
authors.lastname: Crosby
authors.affiliation: Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia.
authors.forename: D Scott
authors.initials: DS
authors.lastname: Lim
authors.affiliation: Investigators for the Virginia Cardiac Surgery Quality Initiative; Division of Cardiothoracic Surgery, Department of Surgery, Virginia Commonwealth University, Richmond, Virginia.
authors.forename: Mohammed A
authors.initials: MA
authors.lastname: Quader
authors.affiliation: Investigators for the Virginia Cardiac Surgery Quality Initiative; Department of Cardiothoracic Surgery, Sentara Heart Hospital, Norfolk, Virginia.
authors.forename: Jeffrey B
authors.initials: JB
authors.lastname: Rich
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001024:Aortic Valve Stenosis / Q000191:economics / Q000401:mortality / Q000601:surgery*; D003365:Costs and Cost Analysis; D005260:Female; D005500:Follow-Up Studies; D017048:Health Care Costs / Q000706:statistics & numerical data*; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D015994:Incidence; D008297:Male; D011183:Postoperative Complications / Q000191:economics / Q000453:epidemiology; D057216:Propensity Score; D012189:Retrospective Studies; D015996:Survival Rate / Q000639:trends; D065467:Transcatheter Aortic Valve Replacement / Q000191:economics*; D014768:Virginia / Q000453:epidemiology