title: Cost-Effectiveness of Transcatheter Aortic Valve Replacement With a Self-Expanding Prosthesis Versus Surgical Aortic Valve Replacement.
abstract: BACKGROUND
  Previous studies of the cost-effectiveness of transcatheter aortic valve replacement (TAVR) have been based primarily on a single balloon-expandable system.
  
  
  OBJECTIVE
  The goal of this study was to evaluate the cost-effectiveness of TAVR with a self-expanding prosthesis compared with surgical aortic valve replacement (SAVR) for patients with severe aortic stenosis and high surgical risk.
  
  
  METHODS
  We performed a formal economic analysis on the basis of individual, patient-level data from the CoreValve U.S. High Risk Pivotal Trial. Empirical data regarding survival and quality of life over 2 years, and medical resource use and hospital costs through 12 months were used to project life expectancy, quality-adjusted life expectancy, and lifetime medical costs in order to estimate the incremental cost-effectiveness of TAVR versus SAVR from a U.S.
  
  
  RESULTS
  Relative to SAVR, TAVR reduced initial length of stay an average of 4.4 days, decreased the need for rehabilitation services at discharge, and resulted in superior 1-month quality of life. Index admission and projected lifetime costs were higher with TAVR than with SAVR (differences $11,260 and $17,849 per patient, respectively), whereas TAVR was projected to provide a lifetime gain of 0.32 quality-adjusted life-years ([QALY]; 0.41 LY) with 3% discounting. Lifetime incremental cost-effectiveness ratios were $55,090 per QALY gained and $43,114 per LY gained. Sensitivity analyses indicated that a reduction in the initial cost of TAVR by ∼$1,650 would lead to an incremental cost-effectiveness ratio <$50,000/QALY gained.
  
  
  CONCLUSIONS
  In a high-risk clinical trial population, TAVR with a self-expanding prosthesis provided meaningful clinical benefits compared with SAVR, with incremental costs considered acceptable by current U.S.
  
  
  METHODS
  With expected modest reductions in the cost of index TAVR admissions, the value of TAVR compared with SAVR in this patient population would become high. (Safety and Efficacy Study of the Medtronic CoreValve System in the Treatment of Symptomatic Severe Aortic Stenosis in High Risk and Very High Risk Subjects Who Need Aortic Valve Replacement [Medtronic CoreValve U.S. Pivotal Trial]; NCT01240902).
authors.affiliation: Harvard Clinical Research Institute, Boston, Massachusetts; Department of Cardiology, Lahey Hospital and Medical Center, Burlington, Massachusetts. Electronic address: matthew.reynolds@hcri.harvard.edu.
authors.forename: Matthew R
authors.initials: MR
authors.lastname: Reynolds
authors.affiliation: Saint Luke's Mid America Heart Institute, Kansas City, Kansas; University of Kansas School of Medicine, Kansas City, Kansas.
authors.forename: Yang
authors.initials: Y
authors.lastname: Lei
authors.affiliation: Saint Luke's Mid America Heart Institute, Kansas City, Kansas.
authors.forename: Kaijun
authors.initials: K
authors.lastname: Wang
authors.affiliation: Saint Luke's Mid America Heart Institute, Kansas City, Kansas.
authors.forename: Khaja
authors.initials: K
authors.lastname: Chinnakondepalli
authors.affiliation: Saint Luke's Mid America Heart Institute, Kansas City, Kansas.
authors.forename: Katherine A
authors.initials: KA
authors.lastname: Vilain
authors.affiliation: Saint Luke's Mid America Heart Institute, Kansas City, Kansas; University of Missouri-Kansas City, Kansas City, Missouri.
authors.forename: Elizabeth A
authors.initials: EA
authors.lastname: Magnuson
authors.affiliation: Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Benjamin Z
authors.initials: BZ
authors.lastname: Galper
authors.affiliation: Piedmont Heart Institute, Atlanta, Georgia.
authors.forename: Christopher U
authors.initials: CU
authors.lastname: Meduri
authors.affiliation: Saint Luke's Mid America Heart Institute, Kansas City, Kansas; University of Missouri-Kansas City, Kansas City, Missouri.
authors.forename: Suzanne V
authors.initials: SV
authors.lastname: Arnold
authors.affiliation: Saint Luke's Mid America Heart Institute, Kansas City, Kansas; University of Missouri-Kansas City, Kansas City, Missouri.
authors.forename: Suzanne J
authors.initials: SJ
authors.lastname: Baron
authors.affiliation: Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Reardon
authors.affiliation: The Icahn School of Medicine at Mount Sinai, New York, New York.
authors.forename: David H
authors.initials: DH
authors.lastname: Adams
authors.affiliation: Beth Israel Deaconess Medical Center, Boston, Massachusetts.
authors.forename: Jeffrey J
authors.initials: JJ
authors.lastname: Popma
authors.affiliation: Saint Luke's Mid America Heart Institute, Kansas City, Kansas; University of Missouri-Kansas City, Kansas City, Missouri.
authors.forename: David J
authors.initials: DJ
authors.lastname: Cohen
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001024:Aortic Valve Stenosis / Q000191:economics / Q000601:surgery*; D003362:Cost-Benefit Analysis; D005260:Female; D006350:Heart Valve Prosthesis / Q000191:economics*; D017721:Hospital Costs; D006801:Humans; D007902:Length of Stay / Q000191:economics; D008297:Male; D011474:Prosthesis Design; D019057:Quality-Adjusted Life Years; D065467:Transcatheter Aortic Valve Replacement / Q000191:economics* / Q000295:instrumentation*; D016896:Treatment Outcome
keywords: aortic stenosis; cost-benefit analysis; heart valve prosthesis; quality-adjusted life-years; transcatheter valve therapy