Abstract 15432: What should be the Threshold for Surgery in the Aortopathy of Bicuspid Aortic Valve [BAV]? A Markov Model of Effectiveness and Cost
Keywords: Aortopathy, BAV, decision-making & cost effectiveness.
Background: The last 2 decades have seen a marked increase in the detection and intervention for aortopathy in BAV. Although there is evidence both for and against an aggressive proactive approach, controversy persists due to the lack of any randomized trials and conflicting messages from registry studies. We developed a Markov model to inform decision-making in this complex problem.
Methods: We considered the index case as a 65 year old with BAV with ascending aorta from 4.5-5.0 cm. Health states were defined as preoperative, postoperative [elective and urgent root surgery, AVR only], post-complication [stroke, renal failure, endocarditis, heart failure] and death. We utilized the available literature to provide the mean and variance of risks, transition probabilities, utilities and the cost associated with elective/urgent aortic valve replacement with or without aortic surgery, reassessed yearly. Sensitivity analyses were performed on all variables using TreeAge Pro software for the model and analyses. Implications for survival, quality-adjusted life years [QALYs] and costs were calculated from a US healthcare perspective.
Results: After 10,000 simulations, life expectancy at full quality of life [QOL] was 6.72±0.01 years for immediate aortic root replacement [ARR] vs. 9.95±0.01 years for watchful waiting [WW]. The net monetary benefit was $607,627±2649 with surgery vs. 982,624±683 with WW. Threshold analysis showed that surgery was not justifiable until the probability of dissection/ rupture reached 11.8%
Conclusions: This decision-analytic model shows that within the constraints of the evidence provided by the current literature, proactive aortic surgery in a BAV patient with aorta less than 5 cm is neither justifiable nor cost effective.
- © 2013 by American Heart Association, Inc.