Cost-Effectiveness of Mitral Valve Repair Versus Replacement for Severe Ischemic Mitral Regurgitation
Authors: Ferket Bart S. , Ailawadi Gorav , Gelijns Annetine C. , Acker Michael A. , Hohmann Samuel F. , Chang Helena L. , Bouchard Denis , Meltzer David O. , Michler Robert E. , Moquete Ellen G. , Voisine Pierre , Mullen John C. , Lala Anuradha , Mack Michael J. , Gillinov A. Marc , Thourani Vinod H. , Miller Marissa A. , Gammie James S. , Parides Michael K. , Bagiella Emilia , Smith Robert L. , Smith Peter K. , Hung Judy W. , Gupta Lopa N. , Rose Eric A. , O’Gara Patrick T. , Moskowitz Alan J. ,   for the Cardiothoracic Surgical Trials Network (CTSN) Investigators*, Taddei-Peters Wendy C. , Buxton Dennis , Geller Nancy L. , Gordon David , Jeffries Neal O. , Lee Albert , Moy Claudia S. , Gombos Ilana Kogan , Ralph Jennifer , Weisel Richard D. , Gardner Timothy J. , Ascheim Deborah D. , Moquete Ellen , Chang Helena , Chase Melissa , Foo James , Gupta Lopa , Kirkwood Katherine , Dobrev Edlira , Levitan Ron , O’Sullivan Karen , Overbey Jessica , Santos Milerva , Williams Deborah , Williams Paula , Ye Xia , Mack Michael , Adame Tracine , Settele Natalie , Adams Jenny , Ryan William , Grayburn Paul , Chen Frederick Y. , Nohria Anju , Cohn Lawrence , Shekar Prem , Aranki Sary , Couper Gregory , Davidson Michael , Bolman R. Morton , Lawrence Rita , Blackstone Eugene H. , Geither Carrie , Berroteran Leoma , Dolney Diana , Doud Kristen , Fleming Suzanne , Palumbo Roberta , Whitman Christine , Sankovic Kathy , Sweeney Denise Kosty , Pattakos Gregory , Clarke Pamela A. , Argenziano Michael , Williams Mathew , Goldsmith Lyn , Smith Craig R. , Naka Yoshifumi , Stewart Allan , Schwartz Allan , Bell Daniel , Van Patten Danielle , Sreekanth Sowmyashree , Alexander John H. , Milano Carmelo A. , Glower Donald D. , Mathew Joseph P. , Harrison J. Kevin , Welsh Stacey , Berry Mark F. , Parsa Cyrus J. , Tong Betty C. , Williams Judson B. , Ferguson T. Bruce , Kypson Alan P. , Rodriguez Evelio , Harris Malissa , Akers Brenda , O’Neal Allison , Puskas John D. , Guyton Robert , Baer Jefferson , Baio Kim , Neill Alexis A. , Senechal Mario , Dagenais François , O’Connor Kim , Dussault Gladys , Ballivian Tatiana , Keilani Suzanne , Speir Alan M. , Magee Patrick , Ad Niv , Keyte Sally , Dang Minh , Slaughter Mark , Headlee Marsha , Moody Heather , Solankhi Naresh , Birks Emma , Groh Mark A. , Shell Leslie E. , Shepard Stephanie A. , Trichon Benjamin H. , Nanney Tracy , Hampton Lynne C. , Mangusan Ralph , D’Alessandro David A. , DeRose Joseph J. , Goldstein Daniel J. , Bello Ricardo , Jakobleff William , Garcia Mario , Taub Cynthia , Spevak Daniel , Swayze Roger , Sookraj Nadia , Perrault Louis P. , Basmadjian Arsène-Joseph , Bouchard Denis , Carrier Michel , Cartier Raymond , Pellerin Michel , Tanguay Jean François , El-Hamamsy Ismael , Denault André , Lacharité Jonathan , Robichaud Sophie , Horvath Keith A. , Corcoran Philip C. , Siegenthaler Michael P. , Murphy Mandy , Iraola Margaret , Greenberg Ann , Sai-Sudhakar Chittoor , Hasan Ayseha , McDavid Asia , Kinn Bradley , Pagé Pierre , Sirois Carole , Young Cindi A. , Beach Dana , Villanueva Robert , Woo Y. Joseph , Mayer Mary Lou , Bowdish Michael , Starnes Vaughn A. , Shavalle David , Matthews Ray , Javadifar Shadi , Romar Linda , Kron Irving L. , Johnston Karen , Dent John M. , Kern John , Keim Jessica , Burks Sandra , Gahring Kim , Bull David A. , Desvigne-Nickens Patrice , Dixon Dennis O. , Haigney Mark , Holubkov Richard , Jacobs Alice , Miller Frank , Murkin John M. , Spertus John , Wechsler Andrew S. , Sellke Frank , McDonald Cheryl L. , Byington Robert , Dickert Neal , Dixon Dennis O. , Ikonomidis John S. , Williams David O. , Yancy Clyde W. , Fang James C. , Giannetti Nadia , Richenbacher Wayne , Rao Vivek , Furie Karen L. , Miller Rachel , Pinney Sean , Roberts William C. , Walsh Mary N. , Hung Judy , Zeng Xin , Kilcullen Niamh , Hung David , Keteyian Steve , Aldred Heather , Brawner Clinton , Mathew Joseph , Browndyke Jeffrey , Toulgoat-Dubois Yanne 
Published: January 2019

Background:
The CTSN (Cardiothoracic Surgical Trials Network) recently reported no difference in left ventricular end-systolic volume index or in survival at 2 years between patients with severe ischemic mitral regurgitation (MR) randomized to mitral valve repair or replacement. However, replacement provided more durable correction of MR and fewer cardiovascular readmissions. Yet, cost-effectiveness outcomes have not been addressed.

Methods and Results:
We conducted a cost-effectiveness analysis of the surgical treatment of ischemic MR based on the CTSN trial (n=126 for repair; n=125 for replacement). Patient-level data on readmissions, survival, quality-of-life, and US hospital costs were used to estimate costs and quality-adjusted life years per patient over the trial duration and a 10-year time horizon. We performed microsimulation for extrapolation of outcomes beyond the 2 years of trial data. Bootstrap and deterministic sensitivity analyses were done to address parameter uncertainty. In-hospital cost estimates were $78 216 for replacement versus $72 761 for repair (difference: $5455; 95% uncertainty interval [UI]: −7784–21 193) while 2-year costs were $97 427 versus $96 261 (difference: $1166; 95% UI: −16 253–17 172), respectively. Quality-adjusted life years at 2 years were 1.18 for replacement versus 1.23 for repair (difference: −0.05; 95% UI: −0.17 to 0.07). Over 5 and 10 years, the benefits of reduction in cardiovascular readmission rates with replacement increased, and survival minimally improved compared with repair. At 5 years, cumulative costs and quality-adjusted life years showed no difference on average, but by 10 years, there was a small, uncertain benefit for replacement: $118 023 versus $119 837 (difference: −$1814; 95% UI: −27 144 to 22 602) and quality-adjusted life years: 4.06 versus 3.97 (difference: 0.09; 95% UI: −0.87 to 1.08). After 10 years, the incremental cost-effectiveness of replacement continued to improve.

Conclusions:
Our cost-effectiveness analysis predicts potential savings in cost and gains in quality-adjusted survival at 10 years when mitral valve replacement is compared with repair for severe ischemic MR. These projected benefits, however, were small and subject to variability. Efforts to further delineate predictors of long-term outcomes in patients with severe ischemic MR are needed to optimize surgical decisions for individual patients, which should yield more cost-effective care.

CLINICAL TRIAL REGISTRATION:

URL:
https://www.clinicaltrials.gov
. Unique identifier: NCT00807040.