Surgical versus transcatheter pulmonary valve replacement after tetralogy of Fallot repair: a clinical decision analysis comparison
Yibei Zhu, Samuel M. Hoenig, Kunaal S. Sarnaik, Shivni Patel, Karl F. Welke, Brian McCrindle, Rashed Mahboubi, Miza Salim Hammoud, Tara KaramlouAbstract
Objective:
The choice between transcatheter and surgical pulmonary valve replacement for young adults with repaired tetralogy of Fallot who develop significant pulmonary valve insufficiency is challenging. Decision analytic modelling may be used to simulate long-term outcomes and suggest influential clinical thresholds for decision-making. A Markov model was constructed to compare the 5-year outcomes for a hypothetical cohort of 18-year-old patients.
Methods:
A Markov model was constructed to simulate 10,000 hypothetical patients undergoing either transcatheter pulmonary valve replacement or surgical pulmonary valve replacement. Model inputs were abstracted from contemporary literature on the 5-year horizon. Outputs were used to derive an incremental cost-effectiveness ratio. Sensitivity and threshold analyses were performed to identify factors that would hypothetically change management.
Results:
From modelling, surgical pulmonary valve replacement had superior survival, lower incidence of endocarditis, and lower reintervention rate compared to transcatheter pulmonary valve replacement at 5 years. Surgical pulmonary valve replacement yielded lower cumulative postprocedural costs ($10,767 versus $14,528) and greater quality-adjusted life years (3.16 versus 3.12 QALYs) than transcatheter pulmonary valve replacement. The calculated incremental cost-effectiveness ratio (−88,743$/QALY) identified surgical pulmonary valve replacement as the preferred strategy at baseline. Sensitivity analysis demonstrated that transcatheter pulmonary valve replacement would be the preferred strategy if either the post-transcatheter pulmonary valve replacement endocarditis rate or the post-transcatheter pulmonary valve replacement surgical reintervention rate were reduced to 0%/month.
Conclusions:
Comprehensive modelling of diverse outcomes showed that surgical pulmonary valve replacement had superior mid-term cost-effectiveness outcomes compared to transcatheter pulmonary valve replacement for young adults with repaired tetralogy of Fallot and pulmonary valve regurgitation. Sensitivity analysis found that the prevalence of post-transcatheter pulmonary valve replacement endocarditis and post-transcatheter pulmonary valve replacement surgical reintervention were influential outcomes for centres to consider when choosing between these strategies.