Subject(s)
Aortic Valve/surgery , Bioprosthesis , Cardiopulmonary Bypass/methods , Constriction , Heart Valve Prosthesis/standards , Inventions , Transcatheter Aortic Valve Replacement/instrumentation , Clinical Trials as Topic , Humans , Quality Improvement , Time Factors , Transcatheter Aortic Valve Replacement/methods , Transcatheter Aortic Valve Replacement/trends , Treatment OutcomeABSTRACT
OBJECTIVE: The recent development of the EDWARDS INTUITY Elite™ (EIE) valve system enables the rapid deployment of a prosthetic surgical heart valve in an aortic valve replacement (AVR) procedure via both the minimally invasive (MISAVR) and conventional (CAVR) approaches. In order to understand its economic value, this study performed a cost evaluation of the EIE valve system used in a MIS rapid-deployment approach (MIS-RDAVR) vs MISAVR and CAVR, respectively, compared to standard prosthetic aortic valves. METHODS: A simulation model was developed using TreeAge (and validated with MS Excel) to compare the inpatient utilization and complication costs for each treatment arm. Thirty-day clinical end-points for the MIS-RDAVR (mortality and complications) were taken from the TRANSFORM trial; and a best evidence review of the published literature was used for the MISAVR and CAVR approaches. Studies were pooled and parameter estimates were weighted by sample size in order to compare the TRANSFORM patients. Cost data (2016 USD) were taken from the Premier database. Incremental cost and cost-effectiveness was assessed and one-way/probabilistic sensitivity analyses performed to gauge the robustness of the results. RESULTS: MIS-RDAVR costs $2,621 less than CAVR and had lower mortality rates, making it a superior (dominant) technology relative to CAVR. MIS-RDAVR costs $4,560 more than MISAVR, but was associated with an additional 0.20 life years-per-patient. This implies a cost-effectiveness ratio of $22,903 per-life-year-gained. Thus, MIS-RDAVR is cost-effective compared to MISAVR. CONCLUSIONS: The EIE valve system deployed in a MIS approach appears to be a cost-effective technology compared to MISAVR and CAVR. When compared to CAVR it may achieve cost savings as well. These results suggest that MIS-RDAVR confers superior economic value compared to both standard MISAVR and CAVR via lowered key complication rates (re-operation, renal complications, wound infection, TIA, endocarditis) and utilization (cross-clamp time, hospital ward days).
Subject(s)
Aortic Valve/surgery , Heart Valve Prosthesis Implantation/economics , Heart Valve Prosthesis Implantation/instrumentation , Aged , Aged, 80 and over , Cost-Benefit Analysis , Humans , Models, Economic , Multicenter Studies as TopicABSTRACT
Obesity has been identified as a risk factor for postoperative atrial fibrillation (POAF) after coronary artery bypass grafting (CABG). However, no studies have addressed the influence of race on this association. A total of 13,594 patients undergoing first-time, isolated CABG without preoperative AF between 1992 and 2011 were included in our study. The association between body mass index and POAF was compared by race. Relative risk and 95% CIs were computed using maximum likelihood log-binomial regression. Increasing levels of body mass index were associated with higher POAF risk after CABG in black but not white patients (pinteraction = 0.0009).
Subject(s)
Atrial Fibrillation/ethnology , Black or African American , Coronary Artery Bypass , Coronary Artery Disease/surgery , Obesity/complications , White People , Aged , Body Mass Index , Coronary Artery Disease/complications , Coronary Artery Disease/ethnology , Female , Humans , Likelihood Functions , Male , Middle Aged , Obesity/ethnology , Regression Analysis , Retrospective Studies , Risk FactorsABSTRACT
Robotic surgery has been applied to various fields in cardiac surgery. Despite excellent results published in the literature, critics have questioned procedure reproducibility, increased cost, and the real patient benefit. We reviewed 5 recent articles to show that robotic cardiac surgery likely will play an important role in the new era of cardiac surgery.
ABSTRACT
The mitral valve has been traditionally approached through a median sternotomy. However, significant advances in surgical optics, instrumentation, tissue telemanipulation, and perfusion technology have allowed for mitral valve surgery to be performed using progressively smaller incisions including the minithoracotomy and hemisternotomy. Due to reports of excellent results, minimally invasive mitral valve surgery has become a standard of care at certain specialized centers worldwide. This meta-analysis quantifies the effects of minimally invasive mitral valve surgery on morbidity and mortality compared with conventional mitral surgery and demonstrates equivalent perioperative mortality (1641 patients, odds ratio (OR) 0.46, 95% confidence interval 0.15-1.42, p=0.18), reduced need for reoperation for bleeding (1553 patients, OR 0.56, 95% CI 0.35-0.90, p=0.02) and a trend towards shorter hospital stays (350 patients, weighted mean difference (WMD) -0.73, 95% CI -1.52 to 0.05, p=0.07). These benefits were evident despite longer cardiopulmonary bypass (WMD 25.81, 95% CI 13.13-38.50, p<0.0001) and cross-clamp times (WMD 20.91, 95% CI 8.79-33.04, p=0.0007) in the minimally invasive group. Case-control studies show consistently less pain and faster recovery compared to those having a conventional approach. Data for minimally invasive mitral valve surgery after previous cardiac surgery are limited but consistently demonstrate reduced blood loss, fewer transfusions and faster recovery compared to reoperative sternotomy. Long-term follow-up data from multiple cohort studies are also examined revealing equivalent survival and freedom from reoperation. Thus, current clinical data suggest that minimally invasive mitral valve surgery is a safe and a durable alternative to a conventional approach and is associated with less morbidity.
