Analysis

Transcatheter aortic valve implantation (TAVI): risky and costly

BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e4710 (Published 31 July 2012) Cite this as: BMJ 2012;345:e4710
  1. Hans Van Brabandt, researcher12,
  2. Mattias Neyt, researcher1,
  3. Frank Hulstaert, researcher1
  1. 1KCE, Belgian Health Care Knowledge Centre, Administratief Centrum Kruidtuin, Kruidtuinlaan 55, 1000 Brussels, Belgium
  2. 2CEBAM, Belgian Centre for Evidence-Based Medicine and Branch of the Dutch Cochrane Centre, Leuven, Belgium
  1. Correspondence to: M Neyt mattias.neyt{at}kce.fgov.be
  • Accepted 2 July 2012

Many of the 40 000 transcatheter procedures so far carried out cannot be justified on medical or cost effectiveness grounds. Hans Van Brabandt, Mattias Neyt, and Frank Hulstaert examine why practice has gone beyond the evidence

Around the world, tens of thousands of people have been treated for a life threatening heart condition using a minimally invasive technique that many see as the wave of the future. Transcatheter aortic valve implantation (TAVI) offers hope to patients too old or too ill for conventional aortic valve replacement operations, and since its introduction 10 years ago it has spread swiftly—by the end of 2011, an estimated 40 000 transcatheter implantations had been done.1 But serious unanswered questions remain over the clinical outcomes and the cost effectiveness of TAVI, as well as the regulatory process that enabled it to gain such a large market so rapidly, particularly in Europe.

Aortic stenosis, the progressive failure of the aortic valve to open fully, is the commonest type of valve disease in elderly people. It is usually treated by valve replacement surgery, but around a third of those who might benefit are turned down because the risks of surgery are too high or because problems such as a calcified aorta or scarring from previous surgery make them unsuitable for surgery.2 Untreated, most will die within five years.3 TAVI offers an alternative, in which a replacement valve is introduced through an artery via a small incision (usually the femoral artery) or, less often, surgically with an incision into the chest and then into the left ventricular apex—the transapical approach.

The numbers who could potentially benefit from TAVI are very large.4 Almost 3% of people over 75 have aortic valve disease,5 which means that in England alone there are more than 100 000 patients …

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