Cost-effectiveness of transcatheter aortic valve implantation versus surgery for high-risk patients with aortic stenosis.

PARTNER (Placement of Aortic Transcatheter Valve Trial) remains the only randomized-controlled trial to compare transcatheter aortic valve implantation (TAVI) with surgical aortic valve replacement (AVR) for patients with severe aortic stenosis (1–3). The survival, symptomatic, and cost benefits of TAVI compared to medical therapy in inoperable patients has been previously demonstrated (2,4). However, optimal treatment for “high-risk” patients remains controversial, and there is conflicting evidence on the cost-effectiveness of TAVI compared to AVR in different healthcare settings. Reynolds et al. (5) should be commended on their economic evaluation of TAVI versus AVR based on a modified intentionto-treat cohort of 647 patients from the PARTNER A trial, which represents the first cost analysis to separately assess the transfemoral (TF) and transapical (TA) approaches. Results of this study reported that the entire TAVI cohort did not demonstrate significant differences in cost-effectiveness compared with AVR. However, when stratified according to access site, patients who underwent the TF approach were more likely to be economically attractive compared with AVR than the TA approach. This finding partially reflects the “transfemoral-first” patient selection process utilized in a number of institutions. Compared with the TF group, the TA group had increased comorbidities, which translated into higher perioperative mortality and morbidity and therefore reduced cost-effectiveness. Some limitations of this study should be discussed. Firstly, major bleeding is known to be more likely after AVR than TAVI, and has been emphasized in the study. However, complications that are more likely to be associated with TAVI, such as stroke, atrioventricular block necessitating pacemaker, significant aortic regurgitation, and conversion to AVR, were not closely examined (6). Secondly, the assumption that TAVI is performed in the catheterization laboratory setting for the TF approach may not be applicable to centers where TAVI is performed in hybrid theaters, which is often the case in institutions learning this procedure. Most importantly, the cost-effectiveness of TAVI compared with AVR is largely dependent on the cost and duration of postoperative hospitalization. It has been shown that patients who undergo surgery have a longer length of hospitalization compared with TAVI, and this increase in cost largely offsets the more expensive cost of the TAVI valve device. For patients who underwent AVR in the PARTNER trial, the mean hospitalization was 16 days, which was comparatively longer than other studies involving