Real-World Health-Economic Considerations Around Aortic-Valve Replacement in a Publicly Funded Health System.

Unstructured Abstract Herein we describe the unique interplay between biomedical ethics, principles of distributive justice, and economic theory in order to highlight the role of health technology assessments to compare therapeutic options for aortic valve replacement. From the perspective of the Canadian healthcare system, transcatheter aortic valve implantation (TAVI) is associated with higher costs but also higher incremental health benefits compared to surgical aortic valve replacement (SAVR). At current willingness to pay thresholds, TAVI is likely cost-effective across the spectrum of risk, from inoperable patients to those at low surgical risk. However, we highlight that there are nuances within each subgroup of surgical risk that merit careful consideration by the Heart-Team. Moreover, incorporation of the patient and their preferences in decision making is key. In particular, in young low risk patients, there remains uncertainty regarding the optimal treatment, with unique concerns around valve durability, valve prosthesis selection, and consideration for special procedures such as the Ross procedure. Nonetheless, current research suggests that universally, patients prefer a less invasive approach compared to a more invasive approach. Finally, we highlight that there remain critical issues around timeliness of access to care and unacceptable geographic inequities across Canada. Further research into alternative funding mechanisms and integrated cross-sector care pathways is necessary to address these issues.