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Canadian Journal of Cardiology

The Economics of Transcatheter Valve Interventions

  • Maneesh Sud
    Affiliations
    Schulich Heart Center, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada

    Sunnybrook Research Institute, Toronto, Ontario, Canada

    Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada

    Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
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  • Derrick Y. Tam
    Affiliations
    Schulich Heart Center, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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  • Harindra C. Wijeysundera
    Correspondence
    Corresponding author: Dr Harindra C. Wijeysundera, 2075 Bayview Ave, Ste A202, Toronto, Ontario M4N 3M5, Canada. Tel.: +1-416-480-4527; fax: +1-416-480-4657.
    Affiliations
    Schulich Heart Center, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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Published:March 24, 2017DOI:https://doi.org/10.1016/j.cjca.2017.03.015

      Abstract

      A subset of patients who require correction of a stenotic or incompetent valve are deemed to be at excessive surgical risk, which precludes surgical repair or replacement. Transcatheter valve interventions are viable alternatives in these patients. However, these technologies are costly, and in the setting of a constrained Canadian health care budget, economic value is an important consideration to allow for fair allocation of scarce resources. Accordingly, we review the economic literature on transcatheter valve interventions, targeting a general audience. Our specific goals are highlighting how best to interpret these studies and discuss the implications of these technologies on the Canadian health care system. Transcatheter aortic valve replacement (TAVR) is a cost-effective alternative for inoperable patients who otherwise would receive medical therapy. When compared with surgical aortic valve replacement (SAVR), TAVR is associated with significant reductions in postprocedure hospital resource use, which offsets the substantially higher cost of the TAVR valve system relative to SAVR valves. Although cost-effectiveness estimates for TAVR in high-risk operable candidates vary widely across studies, based on contemporary data from the perspective of the Canadian health care system, TAVR is likely to provide economic value. Recent studies suggest that when compared with medical therapy for severe degenerative mitral regurgitation, the MitraClip (Abbott, Abbott Park, IL) may offer economic value in high-risk patients; however, in the absence of randomized controlled trials, this is speculative. Nonetheless, these transcatheter technologies represent a paradigm shift in the management of valvular disease; their dissemination will have substantial impact in cardiovascular care delivery.

      Résumé

      Un sous-groupe de patients chez qui une sténose ou une incompétence valvulaire doit être corrigée est réputé présenter un risque chirurgical excessif, qui empêche toute réparation ou implantation chirurgicale. Les interventions valvulaires transcutanées sont des solutions de rechange viables chez ces patients. Cependant, les technologies utilisées à cette fin sont coûteuses, et dans le contexte de restriction budgétaire touchant les soins de santé au Canada, l’avantage économique constitue une considération importante dans l’optique d’une répartition équitable de ressources limitées. En conséquence, nous passons en revue la littérature de nature économique sur les interventions valvulaires transcutanées, en ciblant un public général. Nous nous sommes fixé comme objectifs de cerner la meilleure façon d’interpréter les études sur le sujet et d’aborder les implications des technologies requises pour le système de soins de santé canadien. Le remplacement valvulaire aortique par cathéter (RVAC) est une solution de rechange rentable chez les patients inopérables qui autrement recevraient un traitement médical. Comparativement à la chirurgie de remplacement valvulaire aortique (CRVA), le RVAC est associé à une réduction significative de l’utilisation postopératoire des ressources hospitalières, qui compense le coût beaucoup plus élevé des valves utilisées pour le RVAC par rapport à celles servant à la CRVA. Les estimations du rapport coût-efficacité du RVAC chez les candidats opérables à haut risque varient largement d’une étude à l’autre; néanmoins, d’après les données contemporaines, le RVAC serait probablement avantageux du point de vue économique dans le contexte du système de soins de santé canadien. Des études récentes donnent à penser que, par rapport au traitement médical de l’insuffisance mitrale dégénérative grave, le dispositif MitraClip (Abbott, Abbott Park, IL) peut présenter un avantage économique chez les patients à haut risque; toutefois, en l’absence d’essais randomisés contrôlés, cela relève de la conjecture. Quoi qu’il en soit, les technologies percutanées représentent un changement fondamental dans la prise charge des valvulopathies; leur diffusion aura des répercussions considérables sur la prestation des soins cardiovasculaires.
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