Cost-utility analysis of transcatheter aortic valve implantation versus surgery in severe aortic stenosis patients with intermediate surgical risk in Thailand

BACKGROUND Transcatheter Aortic Valve Implantation(TAVI) has been shown to provide comparable survival benefit and improvement in quality of life to surgical aortic valve replacement(SAVR) for treating patients with severe aortic stenosis(AS) at intermediate surgical risk.This study aimed to evaluate the cost-utility of TAVI compared with SAVR for severe aortic stenosis with interme diate surgical risk in Thailand.METHODS A two-part constructed model was used to analyze lifetime costs and quality-adjusted life-years(QALYs) from societal and healthcare perspectives.The study cohort comprised severe AS patients at intermediate surgical risk with an average age of 80 years.The landmark trials were used to populate the model in terms of mortality and adverse event rates.All cost-related data and quality of life were based on Thai population.Costs and QALYs were discounted at 3% armually and presented as2021 values.Incremental cost-effectiveness ratios(ICERs) were calculated.Deterministic and probabilistic sensitivity analyses were conducted.RESULTS In comparison to SAVR,TAVI resulted in higher total cost(THB 1,717,132 [USD 52;415.51] vs.THB 893,524 [USD27,274.84]) and higher QALYs(4.88 vs.3.98) in a societal perspective.The estimated ICER was THB 906,937/QALY(USD27,684.27/QALY).From a healthcare system perspective,TAVI also had higher total cost than SAVR(THB 1,573,751 [USD48,038.79] vs.THB 726,342 [USD 22,171.63]) with similar QALYs gained to the societal perspective.The estimated ICER was THB933,145/QALY(USD 933,145/QALY).TAVI was not cost-effective at the Thai willingness to pay(WTP) threshold of THB160,000/QALY(USD 4,884/QALY).The results were sensitive to utility of either SAVR or TAVI treatment and cost of TAVI valve.CONCLUSION In patients with severe AS at intermediate surgical risk,TAVI is not a cost-effective strategy compared with SAVR at the WTP of THB 160;000/QALY(USD 4,884/QALY) from the perspectives of society and healthcare system.

Early Prosthetic Valve Endocarditis with Mycobacterium Tuberculosis after Mitral Valve Replacement: A Case Report

Background: Tuberculous endocarditis is a rare but serious complication of heart valve replacement surgery. We report the case of a 24-year-old patient, who presented with tuberculous endocarditis after mechanical mitral valve replacement, with a favorable clinical course following anti-tuberculosis treatment. Case Presentation: We report a 24-year-old male patient, admitted to the cardiac surgery department of the Fann Hospital (Dakar, Senegal), for the management of severe mixed (rheumatic and endocarditic) mitral insufficiency with associated tricuspid insufficiency. He had a history of recurrent angina and polyarthralgia in childhood, was hospitalized several times for refractory global cardiac decompensation, and for a suspected infective endocarditis a month before his admission. On admission, the clinical examination revealed signs suggestive of mitral and tricuspid insufficiency. Transthoracic echocardiography revealed severe post-endocarditic mitral insufficiency with A3 amputation, highly mobile 15 mm vegetations on the free edge of the large valve, moderate tricuspid insufficiency, and severe pulmonary artery hypertension. Mechanical mitral valve replacement and tricuspid valve annuloplasty using autologous pericardial strip were performed via median sternotomy. After ten days, the patient presented with global cardiac decompensation associated with a clinico-biological infectious syndrome, and tans-oesophageal echography revealed an abscess at the sinotubular junction, communicating with the aorta. A thoraco-abdomino-pelvic CT scan was done, which revealed a bilateral alveolar-interstitial syndrome with mediastinal lymphadenopathy. Anti-tuberculosis treatment with RHZE was initiated for 06 months. The clinical course was favorable. Conclusion: Tuberculous endocarditis in prostheses is a serious complication of heart valve replacement surgery, which may evolve favorably under medical treatment.