Surgical and transcatheter pulmonary valve replacement in patients with congenital heart disease, who have a history of right ventricular outflow tract remodeling, Indonesia: A model-based economic evaluation

Background: Patients with congenital heart disease who have previously undergone right ventricular outflow tract (RVOT) surgery frequently require repeat valve replacement later in life. While transcatheter pulmonary valve replacement (TPVR) offers less invasive reintervention compared with surgery, its high device cost raises concerns about affordability under Indonesia’s National Health Insurance Program (Jaminan Kesehatan Nasional). Objectives: To compare the cost-effectiveness of surgical pulmonary valve replacement (SPVR) versus TPVR in post-RVOT surgery patients, and to estimate the TPVR price threshold for cost-effectiveness from a societal perspective. Methods: A Markov model simulated a hypothetical cohort of 15-year-old patients with prior RVOT surgery over their lifetime. Two strategies were evaluated: SPVR repeated every 15 years and TPVR repeated every 10 years. Probability input and costs included procedures and complications, were retrieved from a meta-analysis, hospital data, and published literature. Outcomes included quality-adjusted lifeyears (QALYs), life-years (LYs), and incremental cost-effectiveness ratios (ICERs), discounted at 3% annually. Deterministic sensitivity analysis (DSA) and probabilistic sensitivity analysis (PSA) sensitivity analyses assessed parameter uncertainty. Results: Compared with SPVR, TPVR increased costs by USD 49,765.81, gained 1.47 QALYs and 2.41 LYs, yielding an ICER of USD 33,790.96/QALY. Using a cost-effectiveness threshold of one-time gross domestic product per capita (USD 4,925.40), TPVR was not cost-effective. DSA indicated that the initial SPVR and TPVR utility values had the greatest influence on ICER, while PSA showed TPVR was more effective but substantially more costly. Price-threshold analysis suggested the TPVR valve device cost would need to fall by ~70% (to USD 10,000) to meet the threshold.Conclusion: Under current pricing, TPVR is not cost-effective in Indonesia. These findings support price-negotiation strategies to improve TPVR affordability and advance universal health coverage goals.