Cost-Effectiveness of Valve-in-Valve Transcatheter Aortic Valve Replacement Versus Redo-Surgical Aortic Valve Replacement for Degenerated Bioprosthetic Aortic Valve

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Background: Degenerated bioprosthetic aortic valves are associated with substantial morbidity, mortality, and health care resource use. Treatment options include redo-surgical aortic valve replacement (redo-SAVR) and valve-in-valve transcatheter aortic valve replacement (ViV-TAVR). ViV-TAVR has been associated with shorter length of stay, but its higher device costs have raised uncertainty about its overall economic value. We constructed a decision-analytic model to compare the cost-effectiveness of ViV-TAVR vs redo-SAVR for the management of degenerated bioprosthetic aortic valves. Methods: Cost-effectiveness was evaluated by calculating deaths averted and incremental cost-effectiveness ratios (ICERs). The main outcome was ICER defined as US dollars/deaths averted. Uncertainty was addressed by plotting cost-effectiveness planes and acceptability curves for various willingness-to-pay thresholds. Results: In the probabilistic analysis, the mean total cost of ViV-TAVR was $88,829 (95% CI, $88,554-$89,104) with a 2-month survival probability of 0.97 (95% CI, 0.969-0.970). For redo-SAVR, the mean cost was $91,411 (95% CI, $91,163-$91,659) with a 2-month survival probability of 0.96 (95% CI, 0.959-0.961). ViV-TAVR was the dominant strategy, resulting in a mean ICER of -$259,323 per death averted (95% CI, -$304,599 to -$220,679). ViV-TAVR was cost effective in 57% to 58% of simulations for willingness-to-pay thresholds ranging from $0 to $150,000. Conclusions: ViV-TAVR is an economically dominant strategy for the management of degenerated bioprosthetic aortic valves, yielding lower costs and marginally improved short-term survival relative to redo-SAVR. However, given a moderate degree of decisional uncertainty, trial-level comparative data and longer-term modeling are required to refine these estimates.

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