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OBJECTIVE: To compare cost effectiveness of minimally invasive aortic valve replacement (MIAVR) including upper V-type ministernotomy in the second intercostals spaces and right minithoracotomy in the second intercostal space with full sternotomy for aortic valve replacement (CAVR).
METHODS: The study population consisted of 631 consecutive patients undergoing isolated AVR between 2004 and 2010. Outcomes of 286 patients undergoing MIAVR were compared to 345 patients undergoing CAVR. To determine the least costly and most effective intervention we used data and costs collected after either intervention, quality adjusted life years (QALYs) and monetary cost as measures of effect and the incremental cost effectiveness ratio to assess whether improved efficacy justified increased cost. To calculate the total cost of the procedures we included preoperative preparation costs, cost of the operation, cost of postoperative care in ICU and the ward, blood transfusion rate as well as complications occurrence, and follow-up for the first postoperative year. All utility variables were obtained from the assessment report based on empirical follow-up data from the operated patients in period three, six and twelve months after the operation, which used the EQ-5D instrument to evaluate the utility of different health states.RESULTS: Operative mortality and major complication rates were similar between the groups. Univariate analysis revealed that MIAVR was associated with reduced incidence of allogeneic blood transfusions, a shorter ICU stay (1.39 days vs. 1.66 days, P=0.001), health state obtained with EQ-5D instrument mean utility QALYs per patient three months after operation (MIAVR=0.855 vs. CAVR=0.715 QALYs, P=0.001), six months (MIAVR=0.891 vs. CAVR=0.791 QALYs, P=0.004), twelve months (MIAVR=0.965 vs. CAVR=0.820 QALYs, P=0.0001). The mean costs of procedure per patient (€) at the day of discharge was not significant (MIAVR=8047.03€ vs.CAVR=7480.63 P=0.42) which means average cost per QALY MIAVR=8338.86€ vs. CAVR=9122.71€. Difference or increment between procedures was in 566.4€ with mean utility per patient 0.145 QALY and incremental cost per QALY of MIAVR versus CAVR 3906.2€.
CONCLUSIONS: Minimally invasive aortic valve replacement is a more cost effective alternative to full sternotomy Aortic valve replacement.