LAA Occlusion More Cost-effective Than Both Warfarin and Dabigatran for A-fib Patients

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Percutaneous left atrial appendage (LAA) closure not only successfully prevents stroke in patients with nonvalvular atrial fibrillation (A-fib) but is cost effective compared with warfarin and the novel oral anticoagulant dabigatran, according to a Canadian study published online May 22, 2013, ahead of print in Circulation.

For the analysis, Sheldon M. Singh, MD, of the Sunnybrook Health Sciences Centre (Toronto, Canada), and colleagues developed a simulation model to evaluate the cost-effectiveness of 3 treatment strategies:

  • Dose-adjusted warfarin with a target international normalized ratio of 2.0-3.0
  • Dabigatran 150 mg twice daily (110 mg twice daily for those older than 80 years or those older than 75 years with a creatinine clearance of 30-50 mL/min)
  • LAA occlusion with the Watchman device (Boston Scientific, Natick, MA)

Information on effectiveness of the therapies was derived from the medical literature, while costs, including medication or devices, hospitalization, and physician services, were based on those paid by the Ontario Ministry of Health and Long-Term Care.

LAA Occlusion Bests Anticoagulants

Warfarin therapy had the lowest discounted life expectancy and discounted quality-adjusted life- years (QALYs). LAA occlusion had the greatest survival and advantage in QALYs. Although LAA occlusion was most expensive in terms of discounted lifetime cost, the incremental cost-effectiveness ratio (ICER) showed advantages for both dabigatran and LAA occlusion over warfarin (table 1).

Table 1. Cost Effectiveness


Lifetime Cost (2012 Canadian Dollars)










LAA Occlusion




However, LAA occlusion was no longer cost effective compared with dabigatran when the OR for bleeding on aspirin compared with warfarin was greater than 0.75 or if the OR for stroke compared with warfarin was greater than 1.56.

Based on the baseline distribution of CHA2DS2VASc stroke and HAS-BLED bleeding risk scores, the lifetime incidence of major strokes was projected to be 16.5% for patients prescribed warfarin, 17.3% for those on dabigatran, and 17.4% for patients who received LAA occlusion, whereas intracerebral hemorrhage was assumed to occur in 0.9% of patients receiving warfarin, 0.6% for those receiving dabigatran, and 0.5% for those with LAA occlusion.

Treatment discontinuation was assumed to occur in 16.3% of patients on warfarin and 20.5% on dabigatran, while 9.3% of patients in the LAA group had unsuccessful implantation and received long-term warfarin therapy instead.

‘No-Brainer’ for CMS

“Compared to warfarin, LAA occlusion and dabigatran are cost-effective,” Dr. Singh and colleagues write. “More importantly, our work suggests that a strategy of LAA occlusion is preferable to dabigatran therapy, based on current evidence.”

The authors suggest that because a randomized trial comparing the novel approaches is unlikely, the study will “stimulate clinicians and health policy makers to critically evaluate the merits of each approach.”

In an accompanying editorial, Paul A. Heidenreich, MD, MS, of Stanford University School of Medicine (Palo Alto, CA), observes that “the willingness of a society to pay for a therapy will obviously depend on the society’s wealth.” Since Canada and the United States share a similar GDP per capita, the results of this analysis can be applied to the United States as well, he suggested.

Moreover, Ziyad M. Hijazi, MD, MPH, of Rush University Medical Center (Chicago, IL), told TCTMD in a telephone interview that the Centers for Medicare and Medicaid Services (CMS) should use a similar type of analysis to decide on a reimbursement strategy when and if the Watchman device is approved by the US Food and Drug Administration (FDA). “It should be a no-brainer that this will improve care in the long run, will be better for patient care, and will save them some money,” he said.

This analysis also avoids the need for a randomized trial comparing LAA occlusion with dabigatran, he added, because closure is more cost effective than the novel anticoagulant in the long run.

In a note of caution, Dr. Heidenreich warns that the effects of rapidly changing technology are unpredictable. While LAA occlusion “may ultimately prove to offer good value, policy makers, guideline writers, and clinicians should wait for more definitive data before changing payment, recommendations, or treatment decisions,” he concludes


1. Singh SM, Micieli S, Wijeysundera HC. An economic evaluation of percutaneous left atrial appendage occlusion: Dabigatran and warfarin for stroke prevention in patients with non-valvular atrial fibrillation. Circulation. 2013;Epub ahead of print.

2. Heidenreich PA. Placing a value on new technologies [editorial]. Circulation. 2013;Epub ahead of print.



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  • Drs. Singh, Heidenreich, and Hijazi report no relevant conflicts of interest.