Cost-effectiveness of combined veno-arterial extracorporeal membrane oxygenation and Impella support (ECPELLA) in infarct-related cardiogenic shock.

AIMS: Cardiogenic shock carries high early mortality. Combined veno-arterial extracorporeal membrane oxygenation and Impella support (ECPELLA) may improve outcomes but is costly and unevenly available across Europe. Its incremental clinical and economic value compared with guideline-directed medical therapy (GDMT) remains uncertain.

METHODS

We developed a calibrated partitioned-survival model comparing ECPELLA with GDMT over a 10-year horizon from a statutory health insurance payer perspective (2024€ reference costing environment). Costs, utilities, and survival inputs were derived from contemporary randomized trials and multinational registries. Uncertainty was assessed using probabilistic, deterministic, scenario, and value-of-information analyses. European cost-environment scenarios were explored to assess transferability.

RESULTS

ECPELLA yielded 4.05 quality-adjusted life-years (QALYs) at €195 000 vs. 3.10 QALYs at €95 000 for GDMT (incremental cost €100 000; incremental QALY 0.95), resulting in an incremental cost-effectiveness ratio (ICER) of €105 263 per QALY. Device and intensive care unit (ICU) costs and early survival effects were the main drivers of uncertainty. Cost-effectiveness improved in patients younger than 60 years, those with reversible myocardial dysfunction, early cannulation, and treatment in high-volume centres (ICER €60 000-80 000 per QALY), whereas neutral survival effects produced ICERs exceeding €300 000 per QALY. Value-of-information analysis indicated residual decision uncertainty.

CONCLUSION

ECPELLA increased quality-adjusted survival at higher cost. In the base-case analysis, the ICER was €105 263 per QALY gained. In predefined scenario analyses, ICERs were lower in younger patients, those with recovery potential, early cannulation, and high-volume centres. Residual decision uncertainty was observed in value-of-information analyses.