Global Cost-Effectiveness of Transcatheter vs Surgical Aortic Valve Replacement in Severe Aortic Stenosis: A Systematic Review and Meta-analysis

BACKGROUD

Transcatheter aortic valve replacement (TAVR) is a less invasive treatment option for patients with severe aortic valve stenosis (AS); however, its economic benefits in patients with low to intermediate surgical risk remain controversial and vary by country. We conducted a systematic review to compare the economic benefits of TAVR vs surgical aortic valve replacement (SAVR).

METHODS

We searched 6 databases, including PubMed, Medline, Scopus, Web of Science, Embase, and Clinical Trials for randomised controlled trials on the economic benefits of TAVR with different valve types and SAVR in symptomatic AS patients with low to intermediate surgical risk, from inception to October 2023. We extracted data on quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio (ICER), with ICER converted to 2023 US dollars.

RESULTS

Fifteen studies met the inclusion criteria, with the overall quality ranging from intermediate to high. Among these, TAVR was found to be cost-effective in 14 studies, whereas in 1 study conducted in a developing country, TAVR was not cost-effective. When adjusted to 2023 USD, the ICER values ranged from $3,669 to $340,038 per QALY gained.

CONCLUSIONS

TAVR appears to be a cost-effective alternative to SAVR in patients with low- to intermediate-risk AS. In all studies, TAVR was associated with a significant increase in QALYs compared with SAVR. Because it is an expensive procedure, the cost-effectiveness of TAVR depends on each country's ICER and willingness-to-pay threshold.

Long-term prosthetic-associated subclinical thrombotic events evaluation by cardiac CTA after transcatheter aortic valve implantation: incidence and outcomes

OBJECTIVE

To observe prosthetic-associated subclinical thrombotic events (PASTE) after transcatheter aortic valve implantation (TAVI) by cardiac CTA, and assess their impact on long-term patient outcomes.

MATERIALS

We prospectively and consecutively enrolled 188 patients with severe aortic stenosis treated with TAVI from February 2014 to April 2017. At 5 years, 61 of 141 survived patients who had completed annual follow-up CTA (≥ 5 years) were included. We analyzed PASTE by CTA, including hypoattenuated leaflet thickening (HALT), sinus filling defect (SFD), and prosthesis filling defect (PFD). The primary outcome was a major adverse cardiovascular composite outcome (MACCO) of stroke, cardiac re-hospitalization, and bioprosthetic valve dysfunction (BVD); the secondary outcomes were bioprosthetic hemodynamics deterioration (PGmean) and cardiac dysfunction (LVEF).

RESULTS

During a median follow-up time of 5.25 years, long-term incidence of HALT, SFD, and PFD were 54.1%, 37.7%, and 73.8%, respectively. In the primary outcome, SFD and early SFD were associated with the MACCO (SFD: p = 0.005; early SFD: p = 0.018), and SFD was a predictor of MACCO (HR: 2.870; 95% CI: 1.010 to 8.154, p = 0.048). In the secondary outcomes, HALT was associated with increased PGmean (p = 0.031), while persistent HALT was correlated with ΔPGmean (β = 0.38, p = 0.035). SFD was negatively correlated with ΔLVEF (β = -0.39, p = 0.041), and early SFD was negatively correlated with LVEF and ΔLVEF (LVEF: r = -0.50, p = 0.041; ΔLVEF: r = -0.53, p = 0.030).

CONCLUSIONS

PASTE were associated with adverse long-term outcomes, bioprosthetic hemodynamics deterioration, and cardiac dysfunction. In particular, SFD was a predictor of MACCO and may be a potential target for anticoagulation after TAVI (NCT02803294).

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov ; Unique identifier: NCT02803294.

CRITICAL RELEVANCE STATEMENT

PASTE, especially SFD, after TAVI based on cardiac CTA findings impacts the long-term outcomes of patients which is a predictor of long-term major adverse outcomes in patients and may be a potential target for anticoagulation after TAVI.

KEY POINTS

Transcatheter aortic valve implantation is being used more often; associated subclinical thromboses have not been thoroughly evaluated. Prosthetic-associated subclinical thrombotic events were associated with adverse outcomes, bioprosthetic hemodynamics deterioration, and cardiac dysfunction. Studies should be directed at these topics to determine if they should be intervened upon.

Minimally Invasive Isolated Aortic Valve Replacement in a Potential TAVI Cohort of Patients Aged ≥ 75 Years: A Propensity-Matched Analysis

(1) Background and Objectives: Transcatheter aortic valve implantation is guideline-recommended from the age of 75. However, this European guideline recommendation is based on limited evidence, since no interaction between age and primary outcome has been found in guideline-stated references. This study aimed to compare the short-term outcomes of minimally invasive isolated aortic valve replacement in patients aged ≥ 75 with those of younger patients; (2) Patients and Methods: This retrospective cohort study included 1339 patients who underwent minimally invasive isolated aortic valve replacement at our facility between 2014 and 2022. This cohort was divided into two age-based groups: <75 and ≥75 years. Operative morbidity and mortality were compared between groups. Further analysis was performed using propensity score matching; (3) Results: After matching, 347 pairs of patients were included and analyzed. Despite the higher EuroSCORE II in the ≥75 group (2.2 ± 1.3% vs. 1.80 ± 1.34%, p ≤ 0.001), the 30-day mortality (1.4% vs. 1.2%; p = 0.90) and major adverse cardiac and cerebrovascular events, such as perioperative myocardial infarction (0.0% vs. 1.2%, p = 0.12) and stroke (1.4% vs. 2.6%, p = 0.06), were comparable between both treatment groups; (4) Conclusions: Minimally invasive aortic valve replacement is a safe treatment method for patients aged ≥ 75. Our results indicate that the unilateral cut-off of 75 years is not a limiting factor for performing minimally invasive aortic valve replacement.

National Institute for Health and Care Excellence (NICE) guidance on heart valve disease

The National Institute for Health and Care Excellence (NICE) guidelines are evidence-based recommendations for health and care in England. In late 2021, NICE published its first ever guidance on the investigation and management of adults with heart valve disease. This followed on from recent updates to the international societal practice guidelines on heart valve disease produced by the American College of Cardiology and American Heart Association (in 2020) and the European Society of Cardiology and European Association for Cardiothoracic Surgery (in 2021). The purpose of the NICE guidance has significant differences from societal guidelines, as NICE guidance is designed for implementation within the UK's taxpayer-funded National Health Service and thus must account not just for clinical effectiveness of treatments but cost-effectiveness also. This explains some of the differences between recent recommendations from these bodies, most notably in the treatment of patients with symptomatic severe aortic stenosis, in which NICE clearly explains that cost implications influenced their final guidance (which differs from the recently published European and North American guidelines). The aims of this review article are to provide an overview of the scope and recommendations of the NICE guideline and to compare and contrast the guidelines, highlighting reasons for differences between the guidance from professional societies and NICE and discussing the relative strengths and weaknesses of the NICE guideline.