How to reduce costs in transcatheter aortic valve implantation

Correspondence to Dr Stefan Toggweiler; [email protected] During the past few years, transcatheter aortic valve implantation (TAVI) has become a mature procedure, results have become reproducible and safety has increased. Nevertheless, the overall cost for TAVI is still higher than the cost for surgical aortic valve replacement (SAVR), mainly due to the higher price of the valve. In this journal, Brecker et al published a UK cost utility analysis based on data from the ADVANCE registry (TAVI group) and from the PARTNER B study (medical management group). They found that TAVI is cost-effective, even in the high-risk subgroup of the ADVANCE registry. This analysis is of importance since it includes patients reflecting contemporary patient selection in Europe. Furthermore, unlike most countries, the UK and the USA have made explicit statements about their willingness to pay ratios (£20 000 and US $50 000, respectively). Thus, costeffectiveness analyses in these countries may be of particular interest. Although TAVI appears to be cost-effective, further reduction of index hospitalisation and follow-up costs are certainly desirable. Several strategies may achieve this. Some are evidence based, and some reflect personal and institutional experience (box 1). Patient selection: The patient’s primary problem has to be severe aortic stenosis, with suitable anatomy for the planned TAVI device. If the patient’s primary problem is related to another condition, medical management may be the best option. There is no doubt that lower risk patients will be treated in future. As shown by Brecker et al in this issue of Open Heart, selection of lower risk patients resulted in lower incremental costeffectiveness ratio per quality-adjusted life years gained. Lower risk patients may have shorter hospitalisation times and less complications. Prognosis is better, and the follow-up costs may be lower. Avoid complications: Owing to improved patient selection, operator experience and better materials such as lower profile catheters, complication rates have decreased during the past years. Even stroke rates have come down. Although complications will always remain, lower complication rates can be anticipated in future. Lower rates of complications will result in shorter hospitalisation time and fewer costs. Planning of the procedure is important. For instance, at the Cantonal Hospital Lucerne, the whole team meets before a procedure to discuss important steps such as location of the puncture site, selection of the type and size of the valve and implantation depth. Device cost: Costs for TAVI valves have already decreased (eg, in Switzerland by about 10–15% during the past 3–4 years), and they will certainly decrease further, thus increasing cost-effectiveness of TAVI compared with medical therapy as well as SAVR. In the present analysis, cost for a CoreValve was £14 800, whereas the cost for a surgical valve was £2000. Thus the price for a transcatheter valve was still more than seven times the price of a surgically implanted valve. Transfemoral first approach: Analyses have shown that costs are higher in patients undergoing TAVI through alternative access routes. Therefore, a ‘transfemoral first’ strategy will likely reduce hospitalisation costs. Local anaesthesia: Despite the fact that transfemoral TAVI under conscious sedation is safe, many (experienced) centres still perform TAVI under general anaesthesia. General anaesthesia may facilitate intraprocedural transoesophageal echocardiography, which may allow for early detection of Box 1 How to reduce costs in transcatheter aortic valve implantation (TAVI)?