Transfemoral—But Not Transapical—TAVR More Cost-Effective Than Surgery


In patients with severe aortic stenosis who are at high surgical risk, the cost-effectiveness of transcatheter aortic valve replacement (TAVR) compared with surgery depends on the access site used, according to an analysis of the PARTNER trial published online November 7, 2012, ahead of print in the Journal of the American College of Cardiology. Transfemoral TAVR comes out ahead of surgery at 1 year, while transapical TAVR fails to be economically attractive.

The findings were previously presented in November 2011 at the annual Transcatheter Cardiovascular Therapeutics symposium in San Francisco, CA.

Out of 699 patients enrolled in PARTNER Cohort A, David J. Cohen, MD, MSc, of Saint Luke’s Mid America Heart Institute (Kansas City, MO), and colleagues looked at the 647 who underwent attempted intervention and had complete follow-up data through 12 months. Within the TAVR cohort, 234 patients underwent transfemoral access and 101 required transapical access.

Upfront Costs Offset by Shorter Stay

For both access sites, TAVR required shorter procedural time than surgery but the acquisition cost of $30,000 for the Sapien valve system (Edwards Lifesciences, Irvine, CA) vs. $5,277 for the surgical prosthetic valve translated into higher procedural costs. The length of stay was reduced with TAVR, but more so in the transfemoral group. As a result, only transfemoral TAVR fully matched the total admission cost of surgery (tables 1 and 2).

Table 1. Transfemoral Cohort: Index Admission Resource Use and Costsa

 

TAVR
(n = 239)

Surgery
(n = 217)

P Value

Procedure Duration, min

244

330

< 0.001

Total Hospital Stay, days

10.2

16.4

< 0.001

ICU Stay, days

3.3

5.6

< 0.001

Procedural Cost

$36,652

$14,475

< 0.001

Nonprocedural Cost

$31,705

$53,834

< 0.001

Physician Fees

$4,861

$5,758

< 0.001

Total Admission Cost

$73,219

$74,067

0.84

a Mean values reported.

Table 2. Transapical Cohort: Index Admission Resource Use and Costsa

 

TAVR
(n = 101)

Surgery
(n = 90)

P Value

Procedure Duration, min

224

354

< 0.001

Total Hospital Stay, days

14.7

16.1

0.39

ICU Stay, days

6.6

8.0

0.33

Procedural Cost

$40,368

$15,076

< 0.001

Nonprocedural Cost

$44,909

$57,827

0.03

Physician Fees

$5,642

$6,121

0.13

Total Admission Cost

$90,919

$79,024

0.06

a Mean values reported.

Between discharge and 12 months, resource use and costs were largely similar between surgery and both TAVR arms. TAVR patients tended to need less rehabilitative care and more skilled nursing care, though differences were slight.

Compared with surgery, cumulative 12-month costs were slightly lower for transfemoral TAVR (mean difference -$1,250) but higher for transapical TAVR (mean difference $9,906); neither difference reached statistical significance. Quality-adjusted life years (QALYs) were higher for transfemoral TAVR vs. surgery, while transapical TAVR had comparatively lower QALYs.

Therefore, in the overall population, TAVR resulted in slightly higher 12-month costs and a small gain in QALYs that translated into an incremental cost-effectiveness ratio of $76,877 per QALY gained. However, this estimate proved highly uncertain in repeated iterations of the model. Transfemoral TAVR economically dominated surgery, while surgery surpassed transapical TAVR.

Transapical TAVR May Improve

“In this prospectively designed analysis of 12-month economic outcomes in the PARTNER A trial, we found that TAVR and [surgery] resulted in 12-month costs and QALYs that were sufficiently similar that neither therapy would be clearly preferred over the other on health economic grounds,” Dr. Cohen and colleagues conclude, noting that the disparity between transfemoral and transapical patients can be explained by differences in hospital resource use and short-term clinical outcomes.

With a median of only 4 transapical procedures taking place at each center, they say, the learning curve may also have played a role. “It seems likely that length of stay will shorten with greater experience, and it is conceivable that clinical and [quality-of-life] outcomes after [transapical TAVR] may improve as well,” the researchers suggest. “Indeed, preliminary results from the continued access phase of the PARTNER trial suggest that substantial improvements in clinical outcomes of [transapical TAVR] have already been achieved at the PARTNER centers.”

Additional research is required to determine whether these shifts can positively influence the cost-effectiveness of transapical TAVR, the investigators conclude.

Study Details

Analyses were based on intention to treat. Cumulative 12-month costs were assessed from a US societal perspective and reported in 2010 US dollars. Baseline characteristics were well matched between TAVR and surgery patients. The transapical patients were more apt to have a history of peripheral arterial and cerebrovascular disease compared with their transfemorally treated counterparts.

 


Source:
Reynolds MR, Magnuson EA, Lei Y, 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;Epub ahead of print.

 

 

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Disclosures
  • The PARTNER trial was funded by a research grant from Edwards Lifesciences.
  • Dr. Cohen reports receiving research grants from Abbott Vascular, AstraZeneca, Boston Scientific, Edwards Lifesciences, Eli Lilly, and Medtronic; serving as a consultant to Abbott Vascular and Medtronic; and receiving speaking honoraria from Eli Lilly.

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