An economic analysis of medical and surgical management of aortopathy associated with bicuspid aortic valve

Aims: To develop a cost-effectiveness model to address the outcome and economic implications of different thresholds for surgery in the management of aortopathy associated with bicuspid aortic valve disease (ABAV).

Methods and Results: A model was created from the perspective of an Australian healthcare funding agency. The index case was a 65-year-old with BAV and ascending aorta diameter of 5.0 cm. Health states were defined as; preoperative with dilated aorta, postoperative without complications, post-complication and death. The mean and variance of risks and transition probabilities were taken from a local surgical database and local costs and utilities of elective and urgent thoracic aortic surgery with or without aortic valve replacement, with a sensitivity analysis based on a systematic review. Scenario analyses were provided for other aortic dimensions. Implications for survival, quality-adjusted life years (QALYs) and costs were calculated from healthcare delivery and economic perspectives. After 10,000 simulations for the reference case, the utility of watchful waiting (WW) exceeded that of elective aortic surgery (AoS) (13±4 vs 10±5 QALY). The net monetary benefit was A$351,063±304,965 with immediate aortic surgery [AoS] vs. 534,797±198,570 with watchful waiting surveillance [WW]. The most important variables affecting effectiveness were utility value of survivors, rate of aortic growth and probability of acute aortic event during WW.

Conclusions: This decision-analytic model informed by our practice, as well as a systematic analysis, shows that aortic surgery in a BAV patient with aorta <5 cm diameter is costlier and less effective than watchful waiting.