OBJECTIVES: To assess the cost-effectiveness of transcatheter aortic valve implantation (TAVI) compared with surgical aortic valve replacement (SAVR) in high risk surgical candidates in the Netherlands. METHODS: A lifetime decision-analytic model projected quality-adjusted life years (QALYs), adverse events, and costs of the competing strategies. Event probabilities and utilities were derived from two-year follow-up data of the CoreValve High Risk Study after stratifying by Kansas City Cardiomyopathy Questionnaire (KCCQ) above and below 60 and stroke status. Costs were based on a single-center analysis of pre-operative diagnostics, procedural, index hospitalization, and long-term resource utilization. Costs and effects were discounted at 4% and 1.5% per annum, respectively. In addition to deterministic sensitivity analyses, a “lean scenario” was explored for TAVI which considered a reduced length of stay. RESULTS: In the early post-operative period, a swifter recovery in health-related quality of life was observed after TAVI, along with improved functional cardiovascular outcomes evidenced by a higher proportion of patients in the higher KCCQ stratum. Undiscounted life expectancy increased by 0.65 (5.62 vs 4.97) years after TAVI. Over the lifetime horizon, TAVI was projected to add 0.41 (3.69 vs. 3.27) QALYs at increased cost of €9,048 (€51,068 vs. €42,020), resulting in an incremental cost-effectiveness ratio (ICER) of €21,946 per QALY gained. Results were relatively insensitive to changes in input parameters. Threshold analysis of the "lean scenario" indicated that a further cost reduction of approximately €5,400 would make TAVI the dominant strategy. CONCLUSIONS: TAVI for high-risk surgical candidates is a cost-effective treatment strategy at a level well below commonly accepted Dutch willingness-to-pay thresholds. This favorable health-economic value proposition can be expected to further improve in future years.