Abstract 14356: Watchful Waiting is more Cost-Effective than Early Surgery for Asymptomatic, Severe Aortic Regurgitation
Introduction. Conventional surgical indications in chronic, asymptomatic, severe aortic regurgitation include symptoms, LV dysfunction and LV enlargement. As the condition is slowly-progressive, watchful waiting (WW, yearly review including echocardiography) may be required over a prolonged period, which may be costly. At the same time, the risks and durability of surgery have improved.
Hypothesis. We hypothesized that early surgery might be a justifiable alternative to WW for the long-term management of this patient population.
Methods. A Markov model was developed to assess the most cost-effective management from four strategies: WW or three immediate surgical options—aortic valve repair (AVRep), mechanical (mAVR), and tissue replacement (tAVR). Each strategy could lead to 7 health states, including pre-intervention, post-AVRep, post-mAVR, post-tAVR, stroke, heart failure, and death. Transition probabilities, costs, and utilities were gathered from the literature, and sensitivity analyses were performed on all variables. The model was based on a payor perspective for a base-case 50 year-old patient, with a 4.2%/yr expected probability of meeting the surgical indication threshold in the WW group. TreeAge Pro software was used for the model and analyses.
Results. Baseline results indicated WW to be the most cost-effective strategy, generating 21.2 QALYs at a cost of $239,946. There was an incremental effectiveness of 4.0 QALYs along with an incremental cost of $23,770 for WW when compared to the next most cost-effective treatment, mAVR. Notably, AVRep was the least cost-effective strategy generating 16.6 QALYs at a cost of $273,441. Sensitivity analyses showed no significant change in the results; minor changes in the incremental cost-effectiveness were seen when varying the annual expected probability of surgery (see figure).
Conclusion. WW remains the most cost-effective strategy for chronic, asymptomatic, severe aortic regurgitation.
- © 2011 by American Heart Association, Inc.