OBJECTIVES: Transcatheter aortic valve implantations (TAVI) and sutureless aortic valve replacement (SU-AVR) have been compared in several clinical trials or meta-analyses, indicating differing effectiveness and safety profiles. The approaches also differ in their surgical cost (operating room and device). These results could lead to lower costs and increase in quality of life with SU-AVR. Aim of this work is to assess the incremental cost-utility of SU-AVR versus TAVI for the treatment of intermediate-to-high risk patients in US, Germany, France, Italy, UK and Australia.

METHODS: A patient-level discrete event simulation was developed to compare in-hospital pathways of patients undergoing SU-AVR or TAVI; after discharge, lifetime evolution was modeled using a cohort Markov model. Hospital outcomes for TAVI reproduce data from recent series; in SU-AVR patients, outcomes are obtained by applying relative efficacy estimates from Meco et al. meta-analysis. After discharge, survival depends on the development of para-valvular leak and need for dialysis. A comprehensive third-party payer perspective encompassing both in-hospital and long-term costs was adopted. All costs were expressed as 2017 US dollars.

RESULTS: In-hospital mortality for SU-AVR resulted lower than TAVI (4.1% vs 7.0%) with an analogous improvement in the lifetime survival (5.51 vs 4.26 LYs); patients with SU-AVR lived 1.25 years more than patients undergoing TAVI (IQR 1.03─1.44) with a mean gain of 1.14 QALYs (IQR 0.98─1.31). Both hospital and long-term costs resulted lower for SU-AVR than TAVI with total savings ranging from about $ 4,160, for France, to almost $ 21,000, for US.

CONCLUSIONS: SU-AVR results dominant when compared to TAVI in intermediate-to-high risk patients. Both in-hospital and long-term costs are lower for SU-AVR than for TAVI patients, with concomitant significant gains in life expectancy, both raw and adjusted for quality of life.