Alcohol septal ablation for hypertrophic obstructive cardiomyopathy cost-effectiveness of therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Nehal Eid, M.D.[2]

Cost-effectiveness of therapy

Economic evidence specific to alcohol septal ablation (ASA) for obstructive hypertrophic cardiomyopathy (HCM) is limited. Available studies primarily compare hospitalization costs and subsequent health care utilization after ASA and surgical septal myectomy; no formal quality-adjusted life-year (QALY)-based analysis directly compares the two procedures. Economic evaluations of cardiac myosin inhibitors generally use septal reduction therapy (SRT) as a combined comparator rather than evaluating ASA separately.

Index hospitalization costs

ASA is associated with shorter hospitalization and lower index costs than surgical septal myectomy. In a National Readmission Database analysis of 4,358 patients treated from 2010 through 2015, the following differences were reported:[1]

Index hospitalization costs and length of stay
Population ASA Surgical myectomy
Age ≤65 years Median hospital cost: $15,474 Median hospital cost: $31,531
Age >65 years Median hospital cost: $16,672 Median hospital cost: $36,042
Median length of stay 3 days 6 days

The lower index cost of ASA reflects its less invasive percutaneous approach and avoidance of sternotomy and cardiopulmonary bypass. However, lower index cost should not be interpreted as evidence of lower lifetime cost or superior cost-effectiveness.[2]

Longitudinal utilization and downstream costs

A propensity-weighted claims analysis of 953 patients treated between 2006 and 2018 compared 293 patients undergoing ASA with 660 undergoing myectomy. Over 2 years:[3]

  • Emergency-department visit risk and frequency did not differ significantly (OR 1.1; 95% CI 0.6–1.8).
  • Annual readmission risk during the second postprocedural year was higher after ASA than after myectomy (25.9% versus 10.8%; P=0.004).
  • Among patients who were readmitted, the cumulative length of stay was 1.6 times longer after ASA (incidence rate ratio 1.6; 95% CI 1.0–2.4).
  • Two-year cumulative postprocedural cost was significantly higher after ASA (P<0.001).

Potential drivers of higher downstream expenditure include repeat septal reduction therapy, permanent pacemaker implantation, readmissions, and less complete initial gradient reduction. These associations arise from observational data and do not establish that ASA itself caused the higher costs.[3][4]

A separate Nationwide Readmission Database analysis found an unplanned 30-day readmission rate of 10.4% after ASA. Each readmission was associated with a mean additional cost of $8,433 and 4.9 additional hospital days.[5]

Center experience and economic value

Clinical outcomes after ASA and myectomy are related to institutional and operator experience.

Surgical myectomy

A historical United States hospital-volume analysis covering 2003–2011 found that low-volume hospitals and operators had higher mortality, complication rates, length of stay, and costs after surgical myectomy. In-hospital mortality ranged from 15.6% in the lowest-volume hospital tertile to 3.8% in the highest-volume tertile.[6] These estimates reflect an earlier practice era but demonstrate the clinical and economic importance of center experience.

Alcohol septal ablation

  • Low operator volume was associated with increased 30-day mortality after ASA (adjusted OR 2.99; 95% CI 1.15–7.75).[7]
  • Outcomes improved after institutions had performed more than 50 ASA procedures, including reductions in 30-day cardiovascular mortality from 2.1% to 0.4%, permanent pacemaker implantation from 15% to 9%, and repeat intervention.[8]
  • In a later Euro-ASA analysis, treatment during an institution's first 50 procedures was associated with lower odds of achieving a complete clinical and hemodynamic response (OR 0.49; 95% CI 0.34–0.71).[9]

The 2024 AHA/ACC guideline recommends that SRT be performed at experienced comprehensive HCM centers with demonstrated excellence in clinical outcomes.[2] It is reasonable to infer that fewer complications, readmissions, pacemaker implantations, and repeat procedures improve economic value; however, no study has directly quantified the incremental cost per QALY attributable to center or operator volume.

Cardiac myosin inhibitors and the cost landscape

Cardiac myosin inhibitors introduce a different economic model from SRT: recurring drug acquisition, monitoring, and administrative costs rather than a one-time procedural expenditure.

Mavacamten

  • The reported United States list price of mavacamten was approximately $89,500 per year.[10]
  • The Institute for Clinical and Economic Review concluded that SRT was economically favored at established United States thresholds and estimated a mavacamten health-benefit price benchmark of approximately $12,000–$15,000 per year.[11][10]
  • A separate analysis estimated approximately $1.2 million per additional QALY at the prevailing price, drawing in part on ICER methodology.[12]
  • A Dutch societal-perspective model estimated an incremental cost-effectiveness ratio of €70,223 per QALY gained versus usual care, with a 1.3% probability of cost-effectiveness at a €50,000/QALY threshold. Drug cost and the utility assigned to NYHA functional class I were the most influential model parameters.[13]

Mavacamten may defer or prevent SRT and its associated procedural costs. In VALOR-HCM, approximately 84% of patients remained free of SRT eligibility at 128 weeks.[14] Whether the cost of prolonged therapy and monitoring is offset by avoided procedures, complications, or hospitalizations over a lifetime horizon remains uncertain.

Mavacamten is distributed through a Risk Evaluation and Mitigation Strategy (REMS) program that requires echocardiography before each prescription and dispensing through certified pharmacies. These requirements add monitoring and administrative costs beyond drug acquisition.[15]

Aficamten

Aficamten received its first regulatory approval for symptomatic obstructive HCM in 2025.[16] Formal published cost-effectiveness analyses comparing aficamten with ASA, myectomy, or mavacamten were not available in the supplied evidence.

Clinical application

  1. Do not base treatment selection on index procedural cost alone. ASA has lower initial costs than myectomy, but greater downstream utilization may offset this advantage within 2 years.[1][3]
  2. Incorporate readmissions, permanent pacemaker implantation, repeat SRT, surveillance imaging, medication monitoring, REMS administration, and ongoing drug acquisition into the total value assessment.
  3. Refer patients requiring SRT to experienced comprehensive HCM centers. Clinical appropriateness and center expertise should take priority over local availability or short-term cost differences.[2]
  4. Include the recurring cost of cardiac myosin inhibitors in shared decision-making while recognizing that drug prices, reimbursement, and monitoring requirements vary across health systems.
  5. Do not infer that an economically favored strategy is clinically appropriate for an individual patient. Anatomy, concomitant cardiac disease, procedural risk, expected durability, patient preference, and access to expertise remain central to treatment selection.[2]

Limitations of the economic evidence

  • No formal QALY-based cost-effectiveness analysis directly compares ASA with surgical myectomy.
  • Comparative cost and utilization studies are observational and are vulnerable to residual confounding, selection bias, and incomplete clinical detail in administrative data.
  • Published monetary estimates reflect specific study years, currencies, reimbursement systems, and inflation levels and should not be treated as current local prices.
  • The historical myectomy volume analysis may not reflect contemporary results at specialized HCM centers.[6]
  • Economic evaluations of mavacamten generally compare it with usual care or SRT as a combined category rather than with ASA alone.
  • Model results are sensitive to drug price, treatment duration, health-state utilities, and assumptions regarding durability and avoided procedures.
  • The lifetime economic effect of using a cardiac myosin inhibitor to defer or avoid SRT remains unknown.
  • No formal cost-effectiveness analysis of aficamten was available in the supplied evidence.
  • Geographic variation in procedure pricing, drug reimbursement, monitoring infrastructure, and access to experienced HCM centers limits generalizability.

References

  1. ↑ 1.0 1.1 Lemor A, Villablanca PA, Hosseini Dehkordi SH; et al. (2020). "Comparison of Outcomes of Alcohol Septal Ablation or Septal Myectomy for Hypertrophic Cardiomyopathy in Patients ≤65 Years Versus >65 Years". The American Journal of Cardiology. 127: 128–134. doi:10.1016/j.amjcard.2020.04.018. PMID 32402483 Check |pmid= value (help).
  2. ↑ 2.0 2.1 2.2 2.3 Ommen SR, Ho CY, Asif IM; et al. (2024). "2024 AHA/ACC/AMSSM/HRS/PACES/SCMR Guideline for the Management of Hypertrophic Cardiomyopathy: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines". Journal of the American College of Cardiology. 83 (23): 2324–2405. doi:10.1016/j.jacc.2024.02.014.
  3. ↑ 3.0 3.1 3.2 Sun D, Schaff HV, Van Houten HK; et al. (2022). "Longitudinal Cost of Septal Myectomy Versus Alcohol Septal Ablation for Hypertrophic Cardiomyopathy". Mayo Clinic Proceedings. 97 (9): 1656–1663. doi:10.1016/j.mayocp.2022.02.014. PMID 36058579 Check |pmid= value (help).
  4. ↑ Yokoyama Y, Shimoda T, Shimada YJ; et al. (2023). "Alcohol Septal Ablation Versus Surgical Septal Myectomy of Obstructive Hypertrophic Cardiomyopathy: Systematic Review and Meta-Analysis". European Journal of Cardio-Thoracic Surgery. 63 (3): ezad043. doi:10.1093/ejcts/ezad043. PMID 36782361 Check |pmid= value (help).
  5. ↑ Ando T, Adegbala O, Aggarwal A; et al. (2020). "Unplanned Thirty-Day Readmission After Alcohol Septal Ablation for Hypertrophic Cardiomyopathy (From the Nationwide Readmission Database)". The American Journal of Cardiology. 125 (12): 1890–1895. doi:10.1016/j.amjcard.2020.03.016. PMID 32305221 Check |pmid= value (help).
  6. ↑ 6.0 6.1 Kim LK, Swaminathan RV, Looser P; et al. (2016). "Hospital Volume Outcomes After Septal Myectomy and Alcohol Septal Ablation for Treatment of Obstructive Hypertrophic Cardiomyopathy". JAMA Cardiology. 1 (3): 324–332. doi:10.1001/jamacardio.2016.0252.
  7. ↑ Patel N, Shetty NS, Gaonkar M; et al. (2024). "Procedural Volume and Outcomes After Septal Reduction Therapies in Hypertrophic Obstructive Cardiomyopathy". Journal of the American Heart Association. 13 (21): e036387. doi:10.1161/JAHA.124.036387. PMID 39450721 Check |pmid= value (help).
  8. ↑ Veselka J, Faber L, Jensen MK; et al. (2018). "Effect of Institutional Experience on Outcomes of Alcohol Septal Ablation for Hypertrophic Obstructive Cardiomyopathy". The Canadian Journal of Cardiology. 34 (1): 16–22. doi:10.1016/j.cjca.2017.10.020. PMID 29275877.
  9. ↑ Veselka J, Liebregts M, Cooper R; et al. (2025). "Impact of Centre Experience on Complete Clinical and Haemodynamic Response After Alcohol Septal Ablation for Hypertrophic Obstructive Cardiomyopathy". International Journal of Cardiology: 133865. doi:10.1016/j.ijcard.2025.133865. PMID 40921283 Check |pmid= value (help).
  10. ↑ 10.0 10.1 Ostrominski JW, Guo R, Elliott PM, Ho CY (2023). "Cardiac Myosin Inhibitors for Managing Obstructive Hypertrophic Cardiomyopathy: JACC: Heart Failure State-of-the-Art Review". JACC: Heart Failure. 11 (7): 735–748. doi:10.1016/j.jchf.2023.04.018. PMID 37407153 Check |pmid= value (help).
  11. ↑ Institute for Clinical and Economic Review. Mavacamten for hypertrophic cardiomyopathy: evidence report. 2022.
  12. ↑ Dalo JD, Weisman ND, White CM (2023). "Mavacamten, a First-in-Class Cardiac Myosin Inhibitor for Obstructive Hypertrophic Cardiomyopathy". The Annals of Pharmacotherapy. 57 (4): 489–502. doi:10.1177/10600280221117812. PMID 35950315 Check |pmid= value (help).
  13. ↑ Wiethoff I, Witlox WJA, Evers SMAA, Michels M, Hiligsmann M (2025). "Model-Based Economic Evaluation of the First-in-Class Myosin Inhibitor Mavacamten Versus Care as Usual in Obstructive Hypertrophic Cardiomyopathy Patients From a Dutch Societal Perspective". PharmacoEconomics. doi:10.1007/s40273-025-01564-2. PMID 41261267 Check |pmid= value (help).
  14. ↑ Desai MY, Wolski K, Owens A; et al. (2025). "Mavacamten in Patients With Hypertrophic Cardiomyopathy Referred for Septal Reduction: Week 128 Results From VALOR-HCM". Circulation. 151 (19): 1378–1390. doi:10.1161/CIRCULATIONAHA.124.072445. PMID 39556124 Check |pmid= value (help).
  15. ↑ "CAMZYOS REMS". Bristol-Myers Squibb. Retrieved 2026-08-09.
  16. ↑ Shirley M (2026). "Aficamten: First Approval". Drugs. 86 (6): 949–956. doi:10.1007/s40265-026-02307-z. PMID 41941083 Check |pmid= value (help).
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