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The cost-effectiveness of Maze procedures using ablation techniques at the time of mitral valve surgery

Published online by Cambridge University Press:  12 October 2009

Stéphane P. Quenneville ,
Xuanqian Xie  and
James M. Brophy
Stéphane P. Quenneville
Affiliation:
McGill University Health Centre
Xuanqian Xie
Affiliation:
McGill University Health Centre
James M. Brophy
Affiliation:
McGill University Health Centre
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Abstract

Background: The classic cut and sew surgical Maze procedure has been shown to reduce atrial fibrillation (AF), and recently newer surgical ablation techniques with reduced technical complexity have been introduced. This study sought to systematically review the efficacy and safety of these newer techniques and to evaluate their long-term cost-effectiveness at the time of scheduled mitral valve (MV) surgery.

Methods: A systematic literature search and meta-analysis was performed to generate the most reliable efficacy and safety parameter estimates for a Markov decision analysis model comparing MV surgery alone to MV surgery plus an ablation Maze procedure. Both basic and probabilistic sensitivity analyses were conducted.

Results: Based on the six randomized controlled trials (RCTs) identified, the pooled 1-year estimate of AF after surgery alone was 71 percent (95 percent confidence interval [CI], 64 percent to 78 percent). The pooled risk ratio of AF after surgical ablation treatment at the time of mitral valve surgery relative to valve surgery alone was 0.33 (95 percent CI, 0.19 to 0.55). The pooled analyses showed that no statistical significant increases in operative mortality, permanent pacemaker implantation, and postoperative bleeding with the ablative Maze procedures. An ablation-based Maze procedure at the time of mitral valve surgery had an incremental cost-effectiveness ratio (ICER) of $4,446CAD ($3,850US) per quality-adjusted life-year (QALY) compared with valve surgery alone. Specifically costs were an extra $900CAD but with improved clinical outcomes (0.20 QALYs), including a prolonged life expectancy of 0.10 life-years. In one-way sensitivity analyses, survival time after MV surgery had the largest impact on ICER. Other variables influencing the ICER included the risk ratio of AF, utility, and cost estimates. Probabilistic sensitivity analysis suggests that 58.1 percent, 73.9 percent, and 89.3 percent of the simulations of the Maze strategy are cost-effective at willingness to pay thresholds of $20,000, $50,000, and $100,000CAD per QALY gained, respectively.

Conclusions: Our meta-analysis suggests that a Maze surgical ablation procedure at the time of MV surgery is associated with a reduced postoperative AF risk. Our economic model further suggests that the surgical ablation strategy at the time of mitral valve surgery is likely a cost-effective intervention, provided patients have a good long-term postsurgical prognosis.

Keywords

Atrial fibrillationMitral valve surgeryMazeAblationMeta-analysisMarkov modelCost-effectiveness analysis
Type
General Essays
Information
International Journal of Technology Assessment in Health Care , Volume 25 , Issue 4 , October 2009 , pp. 485 - 496
Copyright
Copyright © Cambridge University Press 2009

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References

REFERENCES

1. Abreu Filho, CA, Lisboa, LA, Dallan, LA, et al. Effectiveness of the maze procedure using cooled-tip radiofrequency ablation in patients with permanent atrial fibrillation and rheumatic mitral valve disease. Circulation. 2005;112 (Suppl):I20–I25.CrossRefGoogle ScholarPubMed
2. Akpinar, B, Guden, M, Sagbas, E, et al. Combined radiofrequency modified maze and mitral valve procedure through a port access approach: Early and mid-term results. Eur J Cardiothorac Surg. 2003;24:223–230.CrossRefGoogle ScholarPubMed
3. Bando, K, Kasegawa, H, Okada, Y, et al. Impact of preoperative and postoperative atrial fibrillation on outcome after mitral valvuloplasty for nonischemic mitral regurgitation. J Thorac Cardiovasc Surg. 2005;129:1032–1040.CrossRefGoogle ScholarPubMed
4. Bank of Canada. Exchange rates. http://www.bank-banque-canada.ca/en/rates/converter.html (accessed May 12, 2009).Google Scholar
5. Barreiro, CJ, Patel, ND, Fitton, TP, et al. Aortic valve replacement and concomitant mitral valve regurgitation in the elderly – Impact on survival and functional outcome. Circulation. 2005;112:I443–I447.CrossRefGoogle ScholarPubMed
6. Baskett, RJF, Buth, KJ, Legare, JF, et al. Is it safe to train residents to perform cardiac surgery? Ann Thorac Surg. 2002;74:1043–1048.CrossRefGoogle ScholarPubMed
7. Benjamin, EJ, Wolf, PA, D'Agostino, RB, Silbershatz, H, Kannel, WB, Levy, D. Impact of atrial fibrillation on the risk of death. Circulation. 1998;98:946–952.CrossRefGoogle ScholarPubMed
8. Blomstrom-Lundqvist, C, Johansson, B, Berglin, E, et al. A randomized double-blind study of epicardial left atrial cryoablation for permanent atrial fibrillation in patients undergoing mitral valve surgery: The SWEDish Multicentre Atrial Fibrillation study (SWEDMAF). Eur Heart J. 2007;28:2902–2908.CrossRefGoogle ScholarPubMed
9. Borger, MA, Yau, TM, Rao, V, Scully, HE, David, TE. Reoperative mitral valve replacement: Importance of preservation of the subvalvular apparatus. Ann Thorac Surg. 2002;74:1482–1487.CrossRefGoogle ScholarPubMed
10. Briggs, AH. Handling uncertainty in cost-effectiveness models. Pharmacoeconomics. 2000;17:479–500.CrossRefGoogle ScholarPubMed
11. Bronnum-Hansen, H, Davidsen, M, Thorvaldsen, P. Long-term survival and causes of death after stroke. Stroke. 2001;32:2131–2136.CrossRefGoogle ScholarPubMed
12. Deneke, T, Khargi, K, Grewe, PH, et al. Efficacy of an additional MAZE procedure using cooled-tip radiofrequency ablation in patients with chronic atrial fibrillation and mitral valve disease. A randomized, prospective trial. Eur Heart J. 2002;23:558–566.CrossRefGoogle ScholarPubMed
13. Doukas, G, Samani, NJ, Alexiou, C, et al. Left atrial radiofrequency ablation during mitral valve surgery for continuous atrial fibrillation: A randomized controlled trial. JAMA. 2005;294:2323–2329.CrossRefGoogle ScholarPubMed
14. Drummond, MF, Sclpher, MJ, Torrance, GW, O'Brien, BJ, Stoddart, GL, eds. Methods for the economic evaluation of health care programs. 3rd ed. Oxford: Oxford University Press; 2005.CrossRefGoogle Scholar
15. Ferraris, VA, Ferraris, SP, Joseph, O, Wehner, P, Mentzer, RM. Aspirin and postoperative bleeding after coronary artery bypass grafting. Ann Surg. 2002;235:820–826.CrossRefGoogle ScholarPubMed
16. Finlayson, GS, Reimer, J, Dahl, M, Stargardter, M, McGowan, KL. The direct cost of hospitalizations in Manitoba, 2005/06. http://mchp-appserv.cpe.umanitoba.ca/reference/HospCost_fullreport.pdf.Google Scholar
17. Ford, ES. Risks for all-cause mortality, cardiovascular disease, and diabetes associated with the metabolic syndrome – A summary of the evidence. Diabetes Care. 2005;28:1769–1778.CrossRefGoogle ScholarPubMed
18. Gillinov, AM, Saltman, AE. Surgical approaches for atrial fibrillation. Med Clin North Am. 2008;92:203–215, xii.CrossRefGoogle ScholarPubMed
19. Gouvernement du Québec. MANUEL DES MÉDECINS SPÉCIALISTES. http://www.ramq.gouv.qc.ca/fr/professionnels/manuels/150/000_complet_acte_spec.pdf (accessed July 17, 2008).Google Scholar
20. Handa, N, Schaff, HV, Morris, JJ, Anderson, BJ, Kopecky, SL, Enriquez-Sarano, M. Outcome of valve repair and the Cox maze procedure for mitral regurgitation and associated atrial fibrillation. J Thorac Cardiovasc Surg. 1999;118:628–635.CrossRefGoogle ScholarPubMed
21. Hardie, K, Hankey, GJ, Jamrozik, K, Broadhurst, RJ, Anderson, C. Ten-year survival after first-ever stroke in the Perth Community Stroke Study. Stroke. 2003;34:1842–1846.CrossRefGoogle ScholarPubMed
22. Hebeler, R. Cryo Maze for the safe and effective surgical treatment of atrial fibrillation. http://www.touchcardiology.com/articles/cryo-maze-safe-effective-a256-1.html (accessed February 12, 2008).Google Scholar
23. Hunink, MG, Glasziou, P, Siegel, J, Weeks, J, Pliskin, J, Elstein, A, eds. Decision making in health and medicine: Integrating evidence and values. Cambridge: Cambridge University Press; 2001.Google Scholar
24. Khargi, K, Hutten, BA, Lemke, B, Deneke, T. Surgical treatment of atrial fibrillation: A systematic review. Eur J Cardiothorac Surg. 2005;27:258–264.CrossRefGoogle ScholarPubMed
25. Khaykin, Y, Morillo, CA, Skanes, AC, McCracken, A, Humphries, K, Kerr, CR. Cost comparison of catheter ablation and medical therapy in atrial fibrillation. J Cardiovasc Electrophysiol. 2007;18:907–913.CrossRefGoogle ScholarPubMed
26. Kim, KC, Cho, KR, Kim, YJ, Sohn, DW, Kim, KB. Long-term results of the Cox-Maze III procedure for persistent atrial fibrillation associated with rheumatic mitral valve disease: 10-year experience. Eur J Cardiothorac Surg. 2007;31:261–266.CrossRefGoogle Scholar
27. Lane, DA, Lip, GY. Quality of life in older people with atrial fibrillation. J Interv Card Electrophysiol. 2009;25:37–42.CrossRefGoogle ScholarPubMed
28. Laupacis, A, Feeny, D, Detsky, AS, Tugwell, PX. How attractive does a new technology have to be to warrant adoption and utilization: Tentative guidelines for using clinical and economic evaluations. CMAJ. 1992;146:473–481.Google ScholarPubMed
29. Leemis, LM, Trivedi, KS. A comparison of approximate interval estimators for the Bernoulli parameter. Am Stat. 1996;50:63–68.CrossRefGoogle Scholar
30. Miners, A, Cairns, J. Probabilistic sensitivity analysis. In: Fox-Rushby, J, Cairns, J, eds. Understanding public health: Economic evaluation. OZGraf SA: Open University Press; 2005:171–183.Google Scholar
31. Miyasaka, Y, Barnes, ME, Gersh, BJ, et al. Time trends of ischemic stroke incidence and mortality in patients diagnosed with first atrial fibrillation in 1980 to 2000: Report of a community-based study. Stroke. 2005;36:2362–2366.CrossRefGoogle ScholarPubMed
32. Prasad, SM, Maniar, HS, Camillo, CJ, et al. The Cox maze III procedure for atrial fibrillation: Long-term efficacy in patients undergoing lone versus concomitant procedures. J Thorac Cardiovasc Surg. 2003;126:1822–1828.CrossRefGoogle ScholarPubMed
33. Public Health Agency of Canada. Major chronic diseases mortality by age group. http://dsol-smed.phac-aspc.gc.ca/dsol-smed/ndis/index_e.html (accessed February 12, 2008).Google Scholar
34. Reston, JT, Shuhaiber, JH. Meta-analysis of clinical outcomes of maze-related surgical procedures for medically refractory atrial fibrillation. Eur J Cardiothorac Surg. 2005;28:724–730.CrossRefGoogle ScholarPubMed
35. Sonnenberg, FA, Beck, JR. Markov-Models in medical decision-making: A practical guide. Med Decis Making. 1993;13:322–338.CrossRefGoogle ScholarPubMed
36. Statistics Canada. Life tables, Canada. http://www.statcan.ca/english/freepub/84-537-XIE/tables.htm (accessed February 12, 2008).Google Scholar
37. Stewart, S, Murphy, N, Walker, A, McGuire, A, McMurray, JJV. Cost of an emerging epidemic: An economic analysis of atrial fibrillation in the UK. Heart. 2004;90:286–292.CrossRefGoogle ScholarPubMed
38. Stulak, JM, Sundt, TM, Dearani, JA, Daly, RC, Orsulak, TA, Schaff, HV. Ten-year experience with the Cox-maze procedure for atrial fibrillation: How do we define success? Ann Thorac Surg. 2007;83:1319–1325.CrossRefGoogle ScholarPubMed
39. Sullivan, PW, Arant, TW, Ellis, SL, Ulrich, H. The cost effectiveness of anticoagulation management services for patients with atrial fibrillation and at high risk of stroke in the US. Pharmacoeconomics. 2006;24:1021–1033.CrossRefGoogle ScholarPubMed
40. Sullivan, PW, Ghushchyan, V. Preference-based EQ-5D index scores for chronic conditions in the United States. Med Decis Making. 2006;26:410–420.CrossRefGoogle ScholarPubMed
41. Teng, J, Mayo, NE, Latimer, E, et al. Costs and caregiver consequences of early supported discharge for stroke patients. Stroke. 2003;34:528–536.CrossRefGoogle ScholarPubMed
42. Vickrey, BG, Rector, TS, Wickstrom, SL, et al. Occurrence of secondary ischemic events among persons with atherosclerotic vascular disease. Stroke. 2002;33:901–906.CrossRefGoogle ScholarPubMed
43. von Oppell, UO, Masani, N, O'Callaghan, P, Wheeler, R, Dimitrakakis, G, Schiffelers, S. Mitral valve surgery plus concomitant atrial fibrillation ablation is superior to mitral valve surgery alone with an intensive rhythm control strategy. Eur J Cardiothorac Surg. 2009;35:641–650.CrossRefGoogle ScholarPubMed
44. Weinstein, MC, Toy, EL, Sandberg, EA, et al. Modeling for health care and other policy decisions: Uses, roles, and validity. Value Health. 2001;4:348–361.CrossRefGoogle ScholarPubMed
45. Wierup, P, Liden, H, Johansson, B, Nilsson, M, Edvardsson, N, Berglin, EWO. Health care consumption due to atrial fibrillation is markedly reduced by maze III surgery. Ann Thorac Surg. 2007;83:1713–1716.CrossRefGoogle ScholarPubMed
46. Wolf, PA, Mitchell, JB, Baker, CS, Kannel, WB, D'Agostino, RB. Impact of atrial fibrillation on mortality, stroke, and medical costs. Arch Intern Med. 1998;158:229–234.CrossRefGoogle ScholarPubMed