Cost-Effectiveness of Thoracotomy Approach for the Implantation of a Small Intrapericardial Centrifugal LVAD

Purpose This is the first assessment of cost-effectiveness of Left Ventricular Assist Device (LVAD) implantation via thoracotomy. Cost effectiveness of LVADs implanted through the traditional surgical approach of sternotomy has been improved through the years due to technological advances, along with understanding the importance patient selection and post-implant management have on positively affecting outcomes. Given the positive clinical outcomes of the thoracotomy approach we seek to study the cost-effectiveness of a small intrapericardial centrifugal LVAD via this less invasive approach. Methods We developed a Markov model to assess the cost-effectiveness of LVAD implantation via thoracotomy. Survival and quality of life inputs for the LVAD arm were based on data from the LATERAL clinical trial. For the Medical Management arm, survival was derived from the Seattle Heart Failure Model. Transplant probability was derived from INTERMACS. Survival after heart transplantation used published UNOS data. Cost inputs were calculated based on Medicare data and past literature. Sensitivity Analyses were conducted. Results The incremental cost-effectiveness ratio (ICER) of a small intrapericardial centrifugal LVAD implantation via thoracotomy was found to be $63,983 per quality adjusted life years (QALY) and $53,387 per life years gained in the bridge to transplant indication. Given the new UNOS heart allocation system, we also examined scenarios of lower transplant rates. In both scenarios the ICER improved and was significantly below the traditional US willingness-to-pay threshold of $50,000/QALY. At 10% transplant rate the ICER was $39,839/QALY and at 5%, $34,468/QALY. We believe this improvement in the ICER is driven by the excellent survival in the LATERAL study. These results demonstrate further improvement in the cost-effectiveness of LVADs and confirm implantation of LVADs via a less invasive approach as being cost-effective. Conclusion In a Markov model assessing the cost-effectiveness of Thoracotomy Approach for the Implantation of LVADs, we found an ICER of $64,684/QALY. In cases of low heart transplant rates the ICER was below $50,000/QALY. These outcomes demonstrate a significant improvement in the ICER and confirm that implantation via thoracotomy of a small intrapericardial centrifugal LVAD in certain scenarios is cost-effective.