TAVR vs SAVR for Aortic Stenosis: Which Procedure Has Greater Cost Savings?

Transfemoral transcatheter aortic valve replacement (TAVR) with the SAPIEN 3 valve has greater cost savings compared with surgical aortic valve replacement (SAVR) at 2 years, according to study findings published in the journal Circulation.

Compared with SAVR, TAVR with SAPIEN 3 has demonstrated superior efficacy at 2 years among patients with low surgical risk who have severe symptomatic aortic stenosis. However, the comparative cost effectiveness has not been evaluated.

The researchers conducted a prespecified analysis from the Placement of Aortic Transcatheter Valves PARTNER 3 (ClinicalTrials.gov Identifier: NCT02675114) trial. Patients (N=929) with severe symptomatic aortic stenosis who were at low surgical risk were randomly assigned in a 1:1 ratio to receive TAVR with the SAPIEN 3 system (n=485) or SAVR (n=444). Costs were estimated using Medicare claims data and the SAVR and TAVR costs included the average device costs ($5900 and $32,500, respectively). Quality-adjusted life years (QALYs) were defined using the EuroQOL 5-item questionnaire. Economic value was defined as an incremental cost-effectiveness ratio (ICER) of less than $50,000 per QALY gained.

The TAVR and SAVR groups were mean age, 73.6 (SD, 5.8) and 74.0 (SD, 6.1) years; 67.4% and 71.6% were men; they had a Society of Thoracic Surgery risk score of 1.9 (SD, 0.7) and 1.9 (SD, 0.6); and 31.5% and 23.9% had a New York Heart Association class III or IV, respectively.

Compared with SAVR, the TAVR procedure was associated with a significantly shorter procedure time (P <.001), lower stroke incidence (P =.016), lower major bleeding rate (P <.001), shorter total hospital stay (P <.001), and a greater rate of discharge to home with self-care (P <.001).

The TAVR and SAVR index procedures cost an average of $37,370 and $18,327 (P <.001) and an associated hospitalization cost of $7174 and $23,578 (P <.001), physician fees of $2652 and $4702 (P <.001), and total index admission cost of $47,196 and $46,606 (P =.586), respectively.

During the 2-year follow-up, the TAVR and SAVR groups had similar rehospitalization and hospital stay usage, however, the TAVR group spent fewer days in a skilled nursing facility (SNF) or in rehabilitation than the SAVR group (difference, -210 days; P <.001).

During the follow-up, the TAVR procedure was associated with a lower SNF and rehabilitation cost (P =.004). Overall, the total follow-up costs of the TAVR and SAVR procedures was $19,638 and $22,258 (P =.132) and cumulative 2-year costs of $66,834 and $68,864 (P =.306), respectively.

For the base case, the TAVR procedure had a 95% probability of being within the $50,000 cost effective cutoff per QALY gained.

Stratified by subgroup, the groups with the greatest probability of being within the margin for cost-effectiveness were patients with left-ventricular ejection fraction (LVEF) of 65% or less (99%), Kansas City Cardiomyopathy Questionnaire (KCCQ) score of 70 or less (98%), NYHA class III/IV (98%), and men (98%). The lowest probability of cost-effectiveness was observed for patients with LVEF greater than 65% (51%).

The researchers noted that “TAVR remained an economically dominant strategy unless the long-term relative risk of death for patients undergoing TAVR versus SAVR was >1.04.”

“[F]or patients with severe AS [aortic stenosis] and low surgical risk, transfemoral TAVR with the SAPIEN 3 valve is economically dominant compared with SAVR at 2-year follow-up and is projected to be highly cost-effective over a lifetime horizon, as long as there are no differences in late mortality between the 2 strategies,” the researchers concluded.

Disclosures: This research was supported by Edwards Lifesciences Inc. Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of disclosures.