Cost-Effectiveness of Left Atrial Appendage Closure for Stroke Prevention in Atrial Fibrillation Patients With Contraindications to Anticoagulation.

BACKGROUND: Percutaneous left atrial appendage closure (LAAC) is increasingly performed as an alternative to oral anticoagulation (OAC) in patients with nonvalvular atrial fibrillation (AF). We sought to evaluate the cost-effectiveness of treating OAC contraindicated patients with LAAC compared with aspirin alone.

METHODS: A probabilistic patient-level Markov microsimulation model with a lifetime horizon was performed to assess the discounted lifetime costs, quality-adjusted life years, and incremental cost-effectiveness ratio of LAAC compared with aspirin for patients with AF with contraindications to OAC. Baseline characteristics were based on a published multicenter Canadian LAAC experience. Clinical events included stroke, bleeding, myocardial infarction, and procedure-related complications. Event rates for stroke and bleeding were based on the CHA2 DS2 -VASc and HAS-BLED scores. The relative efficacies of LAAC and aspirin, as well as utility scores, were obtained from the published literature. Canadian procedural and long-term costs were obtained from the Ontario Case Costing Initiative and the Ontario Ministry of Health and Long Term Care.

RESULTS: Aspirin was less effective than LAAC (4.25 ± 0.53 vs 4.66 ± 0.34 quality-adjusted life years, respectively). The average discounted lifetime cost was CAD$30,748 ± 11,600 for LAAC and $38,974 ± 18,783 for aspirin. Thus, LAAC was dominant, being more effective and less expensive. Our results were robust with a relatively low degree of uncertainty, as LAAC was the preferred option in more than 90% of simulations at a willingness-to-pay threshold of $50,000.

CONCLUSIONS: LAAC is a novel stroke preventative therapy for nonvalvular AF and is a cost-effective alternative to aspirin in patients with contraindications to OAC.