Skip to main content
SpringerLink
Log in

Cost Effectiveness of Transcatheter Aortic Valve Replacement Compared with Medical Management or Surgery for Patients with Aortic Stenosis

  • Systematic Review
  • Published:
Applied Health Economics and Health Policy Aims and scope Submit manuscript

Abstract

Background

In the symptomatic patient, severe aortic stenosis (AS) has an extremely adverse prognosis in the absence of valve replacement, inevitably leading to deterioration of heart function, heart failure, and death. However, many patients with severe AS, advanced age, and comorbid disease may die with AS rather than from AS. While the results of surgical aortic valve replacement (SAVR) are extremely favorable, this technique is not always possible because of either local- or patient-level contraindications. Over the last decade, transcatheter aortic valve replacement (TAVR) has emerged as a new treatment strategy for selected patients with AS. It has now become the standard of care for extremely high-risk (inoperable) patients with AS, and is an appropriate alternative to surgery in high-risk but operable patients. However, whether this intervention is a cost-effective use of resources is open to question

Aim

The aim of this review was to assess the results and quality of the economic evaluations in the current literature and to identify the drivers of cost effectiveness.

Methods

We performed an electronic data search using four different electronic databases, selecting all studies that included cost-effectiveness data for TAVR compared with either medical management or surgery. Sixteen studies were evaluated for a qualitative and quantitative assessment.

Results

The quality of the cost-effectiveness analyses (CEAs) were generally sufficient. In contrast, we found an extreme heterogeneity of input assumptions with consequent difficulties to generalize the conclusions. However, in the population of patients with severe symptomatic AS and a prohibitive surgical risk, TAVR generally represents a good choice, with incremental costs that are well balanced by the great benefit in terms of quality of life and survival. Nevertheless, the cost effectiveness of this procedure in the real world, particularly in patients with high healthcare costs from other comorbid conditions, may be less favorable. In AS patients with high (but not prohibitive) surgical risk, the choice between TAVR and SAVR is still debatable. Both procedures are comparable in terms of efficacy and safety but the evidence is inconclusive from an economic point of view.

Conclusions

On the basis of this review, it was ascertained that the details of risk evaluation and patient selection will be critical in understanding how improvements in survival can be used to target the use of TAVR to ensure the cost-effective and sustainable use of resources.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Iung B. A prospective survey of patients with valvular heart disease in Europe: The Euro Heart Survey on Valvular Heart Disease. Eur Heart J. 2003;24(13):1231–43.

    Article  PubMed  Google Scholar 

  2. Roberts WC, Ko JM. Frequency by decades of unicuspid, bicuspid, and tricuspid aortic valves in adults having isolated aortic valve replacement for aortic stenosis, with or without associated aortic regurgitation. Circulation. 2005;111(7):920–5.

    Article  PubMed  Google Scholar 

  3. Carabello BA, Paulus WJ. Aortic stenosis. Lancet. 2009;373(9667):956–66.

    Article  PubMed  Google Scholar 

  4. Olszowska M. Pathogenesis and pathophysiology of aortic valve stenosis in adults. Pol Arch Med Wewn. 2011;121(11):409–13.

    PubMed  Google Scholar 

  5. Rajamannan NM, et al. Calcific aortic valve disease: not simply a degenerative process. A review and agenda for research from the National Heart and Lung and Blood Institute Aortic Stenosis Working Group. Executive summary: calcific aortic valve disease-2011 update. Circulation. 2011;124(16):1783–91.

    Article  PubMed Central  PubMed  Google Scholar 

  6. Genereux P, et al. Transcatheter aortic valve implantation 10-year anniversary: review of current evidence and clinical implications. Eur Heart J. 2012;33(19):2388–98.

    Article  PubMed  Google Scholar 

  7. Leon MB, et al. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med. 2010;363(17):1597–607.

    Article  CAS  PubMed  Google Scholar 

  8. Smith CR, et al. Transcatheter versus surgical aortic-valve replacement in high-risk patients. N Engl J Med. 2011;364(23):2187–98.

    Article  CAS  PubMed  Google Scholar 

  9. Van Mieghem NM, et al. Complete revascularization is not a prerequisite for success in current transcatheter aortic valve implantation practice. JACC Cardiovasc Interv. 2013;6(8):867–75.

    Article  PubMed  Google Scholar 

  10. Gasparetto V, et al. Safety and effectiveness of a selective strategy for coronary artery revascularization before transcatheter aortic valve implantation. Catheter Cardiovasc Interv. 2013;81(2):376–83.

    Article  PubMed  Google Scholar 

  11. Stortecky S, et al. Transcatheter aortic valve implantation or surgical aortic valve replacement as redo procedure after prior coronary artery bypass grafting. Ann Thorac Surg. 2011; 92(4):1324–30; discussion 1230–1.

  12. Hayashida K, et al. Transcatheter aortic valve implantation for patients with severe bicuspid aortic valve stenosis. Circ Cardiovasc Interv. 2013;6(3):284–91.

    Article  PubMed  Google Scholar 

  13. Bauer T, et al. Comparison of the effectiveness of transcatheter aortic valve implantation in patients with stenotic bicuspid versus tricuspid aortic valves (from the German TAVI Registry). Am J Cardiol. 2014;113(3):518–21.

    Article  PubMed  Google Scholar 

  14. Costopoulos C, et al. Comparison of results of transcatheter aortic valve implantation in patients with severely stenotic bicuspid versus tricuspid or nonbicuspid valves. Am J Cardiol. 2014;113(8):1390–3.

    Article  PubMed  Google Scholar 

  15. Segev A, et al. Trans-catheter aortic valve implantation for non-classical indications. Isr Med Assoc J. 2013;15(8):399–403.

    PubMed  Google Scholar 

  16. Holmes DR Jr, et al. 2012 ACCF/AATS/SCAI/STS expert consensus document on transcatheter aortic valve replacement. J Am Coll Cardiol. 2012;59(13):1200–54.

    Article  PubMed  Google Scholar 

  17. Bonow RO, et al. 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease). Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation. 2008;118(15):e523–661.

    Article  PubMed  Google Scholar 

  18. Cribier A, et al. Percutaneous transcatheter implantation of an aortic valve prosthesis for calcific aortic stenosis: first human case description. Circulation. 2002;106(24):3006–8.

    Article  PubMed  Google Scholar 

  19. Olasinska-Wisniewska A, et al. Transcatheter aortic valve implantation: the new option for high-risk patients with aortic stenosis. Cardiol J. 2011;18(4):461–8.

    PubMed  Google Scholar 

  20. Webb J, Cribier A. Percutaneous transarterial aortic valve implantation: what do we know? Eur Heart J. 2011;32(2):140–7.

    Article  PubMed  Google Scholar 

  21. Forrest JK. Transcatheter aortic valve replacement: design, clinical application, and future challenges. Yale J Biol Med. 2012;85(2):239–47.

    PubMed Central  PubMed  Google Scholar 

  22. Mack MJ, et al. Patient selection for transcatheter aortic valve replacement. J Am Coll Cardiol. 2013;62(17 Suppl):S1–10.

    Article  PubMed  Google Scholar 

  23. Arai T, Lefevre T. Who is the right patient for TAVI? J Cardiol. 2014;63(3):178–81.

    Article  PubMed  Google Scholar 

  24. Petronio AS, et al. Safety and efficacy of the subclavian approach for transcatheter aortic valve implantation with the CoreValve revalving system. Circ Cardiovasc Interv. 2010;3(4):359–66.

    Article  PubMed  Google Scholar 

  25. Li X, et al. Comparison 30-day clinical complications between transfemoral versus transapical aortic valve replacement for aortic stenosis: a meta-analysis review. J Cardiothorac Surg. 2013;8:168.

    Article  PubMed Central  PubMed  Google Scholar 

  26. Reynolds MR, et al. Cost-effectiveness of transcatheter aortic valve replacement compared with surgical aortic valve replacement in high-risk patients with severe aortic stenosis: results of the PARTNER (placement of aortic transcatheter valves) trial (Cohort A). J Am Coll Cardiol. 2012;60(25):2683–92.

    Article  PubMed  Google Scholar 

  27. Al-Attar N, et al. Transcatheter aortic valve implantation: selection strategy is crucial for outcome. Ann Thorac Surg. 2009; 87(6):1757–62; discussion 1762–3.

  28. Kappetein AP, et al. Updated standardized endpoint definitions for transcatheter aortic valve implantation: the Valve Academic Research Consortium-2 consensus document. J Am Coll Cardiol. 2012;60(15):1438–54.

    Article  PubMed  Google Scholar 

  29. Nishimura RA, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. Circulation. 2014;129(23):e521–643.

    Article  PubMed  Google Scholar 

  30. Roques F, et al. Risk factors for early mortality after valve surgery in Europe in the 1990s: lessons from the EuroSCORE pilot program. J Heart Valve Dis. 2001;10(5):572–7; discussion 577–8.

  31. O’Brien SM, et al. The Society of Thoracic Surgeons 2008 cardiac surgery risk models: part 2—isolated valve surgery. Ann Thorac Surg. 2009;88(1 Suppl):S23–42.

    Article  PubMed  Google Scholar 

  32. Piazza N, et al. Relationship between the logistic EuroSCORE and the Society of Thoracic Surgeons Predicted Risk of Mortality score in patients implanted with the CoreValve ReValving system: a Bern-Rotterdam Study. Am Heart J. 2010;159(2):323–9.

    Article  PubMed  Google Scholar 

  33. Fried LP, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146–56.

    Article  CAS  PubMed  Google Scholar 

  34. Afilalo J, et al. Gait speed as an incremental predictor of mortality and major morbidity in elderly patients undergoing cardiac surgery. J Am Coll Cardiol. 2010;56(20):1668–76.

    Article  PubMed  Google Scholar 

  35. Schoenenberger AW, et al. Predictors of functional decline in elderly patients undergoing transcatheter aortic valve implantation (TAVI). Eur Heart J. 2013;34(9):684–92.

    Article  CAS  PubMed  Google Scholar 

  36. Drummond MF, Sculpher MJ, Torrance GW, O’Brien BJ, Stoddart GL. Methods for the economic evaluation of health care programmes. 3rd ed. Oxford: Oxford University Press; 2005.

  37. Detsky AS, Naglie IG. A clinician’s guide to cost-effectiveness analysis. Ann Intern Med. 1990;113(2):147–54.

    Article  CAS  PubMed  Google Scholar 

  38. Hoch JS, Dewa CS. A clinician’s guide to correct cost-effectiveness analysis: think incremental not average. Can J Psychiatry. 2008;53(4):267–74.

    PubMed  Google Scholar 

  39. Eaton J, et al. Is transcatheter aortic valve implantation (TAVI) a cost-effective treatment in patients who are ineligible for surgical aortic valve replacement? A systematic review of economic evaluations. J Med Econ. 2014;17(5):365–75.

    Article  PubMed  Google Scholar 

  40. Indraratna P, et al. Systematic review of the cost-effectiveness of transcatheter aortic valve implantation. J Thorac Cardiovasc Surg. 2014;148:509–14.

  41. Battaglia S, Mazzucco W, Ricciardi W. Cost effectiveness of aortic valve therapies: a systematic review of the literature. Epidemiol Biostat Public Health. 2013;10(4)1–12.

    Google Scholar 

  42. Malaisrie SC. Is transcatheter aortic valve implantation cost effective in the nonsurgical elderly population? Interv Cardiol (Lond). 2013;5(4):411–8.

    Article  Google Scholar 

  43. Boothroyd LJ, et al. Transcatheter aortic valve implantation: recommendations for practice based on a multidisciplinary review including cost-effectiveness and ethical and organizational issues. Can J Cardiol. 2013;29(6):718–26.

    Article  PubMed  Google Scholar 

  44. Neyt M, et al. A cost-utility analysis of transcatheter aortic valve implantation in Belgium: focusing on a well-defined and identifiable population. BMJ Open. 2012;2(3):e001032.

  45. Lopes MACQ, et al. Transcatheter aortic valve implantation for the treatment of severe aortic valve stenosis in inoperable patients under the perspective of the Brazilian supplemental health system: cost-effectiveness analysis. Rev Bras Cardiol Invasiva. 2013;21(3):213–20.

  46. Hancock-Howard RL, et al. Cost effectiveness of transcatheter aortic valve replacement compared to medical management in inoperable patients with severe aortic stenosis: Canadian analysis based on the PARTNER Trial Cohort B findings. J Med Econ. 2013;16(4):566–74.

    Article  PubMed  Google Scholar 

  47. Reynolds MR, et al. Cost-effectiveness of transcatheter aortic valve replacement compared with standard care among inoperable patients with severe aortic stenosis: results from the placement of aortic transcatheter valves (PARTNER) trial (Cohort B). Circulation. 2012;125(9):1102–9.

    Article  PubMed  Google Scholar 

  48. Orlando R, et al. Cost-effectiveness of transcatheter aortic valve implantation (TAVI) for aortic stenosis in patients who are high risk or contraindicated for surgery: a model-based economic evaluation. Health Technol Assess. 2013;17(33):1–86.

    Article  CAS  PubMed  Google Scholar 

  49. Fairbairn TA, et al. The cost-effectiveness of transcatheter aortic valve implantation versus surgical aortic valve replacement in patients with severe aortic stenosis at high operative risk. Heart. 2013;99(13):914–20.

    Article  PubMed  Google Scholar 

  50. Doble B, et al. Cost-effectiveness of the Edwards SAPIEN transcatheter heart valve compared with standard management and surgical aortic valve replacement in patients with severe symptomatic aortic stenosis: a Canadian perspective. J Thorac Cardiovasc Surg. 2013;146(1):52–60.e3.

  51. Watt M, et al. Cost-effectiveness of transcatheter aortic valve replacement in patients ineligible for conventional aortic valve replacement. Heart. 2012;98(5):370–6.

    Article  PubMed  Google Scholar 

  52. Osnabrugge RL, et al. Costs of transcatheter versus surgical aortic valve replacement in intermediate-risk patients. Ann Thorac Surg. 2012;94(6):1954–60.

    Article  PubMed  Google Scholar 

  53. Gada H, et al. Markov model for selection of aortic valve replacement versus transcatheter aortic valve implantation (without replacement) in high-risk patients. Am J Cardiol. 2012;109(9):1326–33.

    Article  PubMed  Google Scholar 

  54. Gada H, Agarwal S, Marwick TH. Perspective on the cost-effectiveness of transapical aortic valve implantation in high-risk patients: outcomes of a decision-analytic model. Ann Cardiothorac Surg. 2012;1(2):145–55.

    PubMed Central  PubMed  Google Scholar 

  55. Sehatzadeh S, et al. Transcatheter aortic valve implantation (TAVI) for treatment of aortic valve stenosis: an evidence update. Ont Health Technol Assess Ser. 2013;13(1):1–40.

    CAS  Google Scholar 

  56. Scottish Health Technologies Group. Evidence development pilot project: transcatheter aortic valve implantation in Scotland. 2010. Available from http://www.gla.ac.uk/medial/media_218806_en.pdf. Accessed Oct 2014

  57. Murphy A, et al. Transcatheter aortic valve implantation for severe aortic stenosis: the cost-effectiveness case for inoperable patients in the United Kingdom. Int J Technol Assess Health Care. 2013;29(1):12–9.

    Article  PubMed  Google Scholar 

  58. Simons CT, et al. Transcatheter aortic valve replacement in nonsurgical candidates with severe, symptomatic aortic stenosis: a cost-effectiveness analysis. Circ Cardiovasc Qual Outcomes. 2013;6(4):419–28.

    Article  PubMed  Google Scholar 

  59. Walker DG, et al. Best practices for conducting economic evaluations in health care: a systematic review of quality assessment tools. Rockville; Agency for Healthcare Research and Quality;2012.

  60. Philips Z, et al. Good practice guidelines for decision-analytic modelling in health technology assessment: a review and consolidation of quality assessment. Pharmacoeconomics. 2006;24(4):355–71.

    Article  PubMed  Google Scholar 

  61. Drummond MF, Jefferson TO. Guidelines for authors and peer reviewers of economic submissions to the BMJ. The BMJ Economic Evaluation Working Party. BMJ. 1996;313(7052):275–83.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  62. Husereau D, et al. Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement. BMJ. 2013;346:f1049.

    Article  PubMed  Google Scholar 

  63. Husereau D, et al. Consolidated Health Economic Evaluation Reporting Standards (CHEERS): explanation and elaboration. A report of the ISPOR Health Economic Evaluation Publication Guidelines Good Reporting Practices Task Force. Value Health. 2013;16(2):231–50.

    Article  PubMed  Google Scholar 

  64. Reynolds MR, et al. Health-related quality of life after transcatheter aortic valve replacement in inoperable patients with severe aortic stenosis. Circulation. 2011;124(18):1964–72.

    Article  PubMed  Google Scholar 

  65. Reynolds MR, et al. Health-related quality of life after transcatheter or surgical aortic valve replacement in high-risk patients with severe aortic stenosis: results from the PARTNER (Placement of AoRTic TraNscathetER Valve) Trial (Cohort A). J Am Coll Cardiol. 2012;60(6):548–58.

    Article  PubMed  Google Scholar 

  66. Makkar RR, et al. Transcatheter aortic-valve replacement for inoperable severe aortic stenosis. N Engl J Med. 2012;366(18):1696–704.

    Article  CAS  PubMed  Google Scholar 

  67. Popma JJ, et al. Transcatheter aortic valve replacement using a self-expanding bioprosthesis in patients with severe aortic stenosis at extreme risk for surgery. J Am Coll Cardiol. 2014;63(19):1972–81.

  68. Kodali SK, et al. Two-year outcomes after transcatheter or surgical aortic-valve replacement. N Engl J Med. 2012;366(18):1686–95.

    Article  CAS  PubMed  Google Scholar 

  69. Adams DH, et al. Transcatheter aortic-valve replacement with a self-expanding prosthesis. N Engl J Med. 2014;370:1790–8.

  70. Shiroiwa T, et al. International survey on willingness-to-pay (WTP) for one additional QALY gained: what is the threshold of cost effectiveness? Health Econ. 2010;19(4):422–37.

    Article  PubMed  Google Scholar 

  71. Mark DB, Hlatky MA. Medical economics and the assessment of value in cardiovascular medicine: part II. Circulation. 2002;106(5):626–30.

    Article  PubMed  Google Scholar 

  72. Mark DB, Mentz RJ. The placement of aortic transcatheter valve (PARTNER) trial: a health economic and policy perspective. Circulation. 2012;125(25):3243–5.

    Article  PubMed  Google Scholar 

Download references

Conflict of interest

Andrea Iannaccone and Thomas Marwick have no conflicts of interest. No external funding was used in the production of this work.

Author Contributions

Andrea Iannaccone performed the search and performed the primary review of the papers. Thomas Marwick designed the study and reviewed the paper selection. Both authors contributed tothe analysis, drafting, and editing of the document. Andrea Iannaccone is the guarantor for the overall content.

Author information

Authors and Affiliations

  1. Menzies Research Institute Tasmania, 17 Liverpool St, Hobart, TAS, 7000, Australia

    Andrea Iannaccone & Thomas H. Marwick

Authors
  1. Andrea Iannaccone
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Thomas H. Marwick
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Thomas H. Marwick.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Iannaccone, A., Marwick, T.H. Cost Effectiveness of Transcatheter Aortic Valve Replacement Compared with Medical Management or Surgery for Patients with Aortic Stenosis. Appl Health Econ Health Policy 13, 29–45 (2015). https://doi.org/10.1007/s40258-014-0141-6

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40258-014-0141-6

Keywords

Search

Navigation