Abstract 23239: Cost-Effectiveness of Repair versus Replacement for Severe Ischemic Mitral Regurgitation: A Randomized Clinical Trial From the Cardiothoracic Surgical Trials Network
Background: We recently reported no difference in left ventricular end systolic volume index (LVESVI) or survival at 2 years post surgery between patients with severe ischemic MR randomized to mitral valve (MV) repair (n=126) or replacement (n=125). However, MV replacement provided more durable correction of MR, as well as fewer heart failure events and cardiovascular readmissions over time. These events have important clinical and economic implications, requiring a cost-effectiveness analysis to elucidate.
Methods: We conducted a cost-effectiveness analysis using patient-level cost and clinical data from the trial, and developed a microsimulation model for projecting readmission rates and mortality events over a 10-year period. Andersen-Gill modelling was used for these projections, accounting for competing risks. We performed bootstrap resampling to assess parameter uncertainty and threshold analyses to test model assumptions.
Results: The mean age of the trial cohort was 68±10 years, mean baseline LVESVI was 63.4±26.8, and 2-year mortality was 19.0% for MV repair and 23.2% for MV replacement patients (HR 0.79, 95% CI 0.46-1.35; p=0.39). The clinical outcomes of the model will be expressed in quality-adjusted life years using longitudinally measured SF-6D scores. Cost outcomes will be derived from claims data using cost-to-charge ratios, and include the index hospitalization and all readmissions. Predictive validity was established by developing the microsimulation model in 1-year data and comparing predicted with observed outcomes at 2 years (Figure).
Conclusions: The benefits of these procedures, which have upfront risks and costs, extend beyond 2 years. Our cost-effectiveness analysis will delineate the long-term cost-benefit trade-offs between MV repair versus replacement that should inform surgical decision making, and examine how differences in life expectancy and risk profiles of different patient groups affect cost-effectiveness.
Author Disclosures: B.S. Ferket: None. G. Ailawadi: None. A. Gelijns: None. M.A. Acker: Consultant/Advisory Board; Modest; Thoratec. S.F. Hohmann: None. H. Chang: None. D. Bouchard: None. D. Meltzer: None. R.E. Michler: None. E. Moquete: None. P. Voisine: None. J.C. Mullen: None. M. Mack: None. A.M. Gillinov: Other Research Support; Modest; St. Jude Medical, Abbott. Consultant/Advisory Board; Modest; St. Jude Medical, Edwards Lifesciences. Consultant/Advisory Board; Significant; Abbott, Medtronic, CryoLife, AtriCure. V. Thourani: Research Grant; Modest; Edwards Lifesciences, Medtronic Corp., Abbott Medical. Consultant/Advisory Board; Modest; Edwards Lifesciences, Abbott Medical. M.A. Miller: None. J. Gammie: None. M. Parides: None. E. Bagiella: None. R.L. Smith: Research Grant; Significant; Edwards LifeSciences. Speakers Bureau; Significant; Abbott Medical. Consultant/Advisory Board; Significant; Abbott Medical, Edwards LifeSciences. Other; Significant; Abbott Medical, Edwards LifeSciences. P.K. Smith: None. J.W. Hung: None. L. Gupta: None. E.A. Rose: None. P. O’Gara: None. A. Moskowitz: None.
- © 2016 by American Heart Association, Inc.