Economic option value associated with surgical aortic valve replacement using a novel bioprosthetic and a future transcatheter aortic valve-in-valve procedure.

Abstract

Introduction: Optimal lifetime management of surgical aortic valve replacement (SAVR) patients should account for the expected clinical and economic value of the index procedure as well as the future trajectory of health outcomes. This study estimates the discounted per surgery "total value" (from the time of initial SAVR operation through 25 years post-surgery) and the option value (after reoperation) that mechanical SAVR patients forego by choosing a device that does not allow for valve-in-valve transcatheter aortic valve reoperation (ViV/TAVR).

Methods: The model adopts a US payer perspective and tracks major health events, anti-coagulant monitoring, maintenance, and expenditures associated with these events following initial SAVR procedures, inclusive of costs before and after a potential reoperation. We compare the expected utilization and expenditures for tissue valve patients and mechanical valve patients over a 25-year period. The model also compares the experience of mechanical SAVR patients after reoperation to a counterfactual group receiving ViV/TAVR to estimate option value. Monte Carlo simulation, sensitivity analyses, scenario analyses, and break-even analyses were conducted to account for variation in inputs.

Results: Novel SAVR treatment for aortic stenosis followed by ViV TAVR for reoperation reduces 25-year payer expenditures relative to mechanical valves by either $34,621 (95% CI: 17,426-52,218), $31,363 (95% CI: $19,871 -$43,399) or $23,303 (95% CI: $16,906-$30,075) depending on the age of initial SAVR operation. During this period, the "option value" share of overall savings ranges from 8-17% and generally is lower for older patients. Reoperation and anti-coagulant monitoring are important drivers of overall savings and option value.

Conclusion: The deterministic and simulation models both demonstrate that novel SAVR tissue valves, followed by a ViV/TAVR, result in lower 25-year expected costs than a treatment strategy using mechanical SAVR valves, and option value is a component of these savings.