HIQA: TAVI is a safe and cost-effective alternative to open heart surgery for patients with severe symptomatic aortic stenosis

Thursday 5 December 2019: The Health Information and Quality Authority (HIQA) has today published a health technology assessment (HTA) recommending that the Minister for Health and the Health Service Executive (HSE) consider extending transcatheter aortic valve implantation (TAVI) — a minimally-invasive alternative to open heart surgery — to patients with severe symptomatic aortic stenosis at intermediate and low risk of surgical complications in the Irish public health care system.

HIQA undertook this HTA at the request of the HSE. Currently TAVI is primarily offered as an alternative to surgical aortic valve replacement (SAVR) in patients that are otherwise inoperable or at high risk of surgical complications.

Aortic stenosis arises when one of the four valves of the heart becomes narrowed, making it difficult for the heart to function properly. The condition typically affects older people, those aged 70 years or older, but it can also occur in younger patients.

HIQA’s Chief Scientist, Dr Conor Teljeur, said: “Clinical trials have demonstrated that TAVI is just as safe as SAVR in terms of cardiac and all-cause mortality. Although some other complications differ between TAVI and SAVR, the minimally invasive procedure is associated with a shorter length of stay in hospital and improved health-related quality of life gains in the short term (up to three months) compared with open heart surgery.”

Between 3% and 4% of adults aged 75 years and older have severe aortic stenosis, of which three-quarters are symptomatic. If left untreated, 40% of patients with the condition will die within five years which is about double the mortality rate of their peers. Replacing or repairing the damaged valve is the only known cure. Standard care, or so called surgical aortic valve replacement (SAVR), involves open heart surgery to replace the damaged valve. As TAVI does not involve open surgery it may offer health benefits to patients, such as faster recovery from the procedure.

With fewer costs arising from a shorter hospital stay, and improved quality of life gains arising from a faster recovery time, TAVI is considered more cost-effective than SAVR in patients at intermediate and low surgical risk in Ireland. There would also be no additional cost to the HSE over the next five years if TAVI was provided to these patients instead of SAVR. However, the long-term durability of TAVI valves is uncertain, and there is limited evidence to support the use of TAVI in patients under 70 years of age.

Dr Teljeur continued: “Extending TAVI to patients at lower levels of surgical risk is likely to be no more expensive to the HSE over the next five years than if patients were to continue to be treated using SAVR. The economic advantage of TAVI is in the reduced length of stay in hospital. By switching patients from SAVR to TAVI, there will be an opportunity to release hospital beds, surgical staff, and theatre time to address other demands in the healthcare system.”

The HTA of TAVI in patients with severe symptomatic aortic stenosis at low and intermediate-risk of surgical complications was approved by the Board of HIQA last week and has been submitted to the Minister for Health, Department of Health, and the HSE for consideration. The HTA is available on www.hiqa.ie, and includes an executive summary and a plain English summary.