Cost-effectiveness of coronary artery bypass grafting plus mitral valve repair versus coronary artery bypass grafting alone for moderate ischemic mitral regurgitation

Bart S. Ferket, Vinod H. Thourani, Pierre Voisine, Samuel F. Hohmann, Helena L. Chang, Peter K. Smith, Robert E. Michler, Gorav Ailawadi, Louis P. Perrault, Marissa A. Miller, Karen O'Sullivan, Stephanie L. Mick, Emilia Bagiella, Michael A. Acker, Ellen Moquete, Judy W. Hung, Jessica R. Overbey, Anuradha Lala, Margaret Iraola, James S. GammieAnnetine C. Gelijns, Patrick T. O'Gara, Alan J. Moskowitz, Wendy C. Taddei-Peters, Dennis Buxton, Ron Caulder, Nancy L. Geller, David Gordon, Neal O. Jeffries, Albert Lee, Claudia S. Moy, Ilana Kogan Gombos, Jennifer Ralph, Richard Weisel, Timothy J. Gardner, Eric A. Rose, Michael K. Parides, Deborah D. Ascheim, Helena Chang, Melissa Chase, Yingchun Chen, Seth Goldfarb, Lopa Gupta, Katherine Kirkwood, Edlira Dobrev, Ron Levitan, Jessica Overbey, Milerva Santos, Michael Weglinski, Paula Williams, Carrie Wood, Xia Ye, Sten Lyager Nielsen, Henrik Wiggers, Henning Malgaard, Michael Mack, Tracine Adame, Natalie Settele, Jenny Adams, William Ryan, Robert L. Smith, Paul Grayburn, Frederick Y. Chen, Anju Nohria, Lawrence Cohn, Prem Shekar, Sary Aranki, Gregory Couper, Michael Davidson, R. Morton Bolman, Anne Burgess, Debra Conboy, Nicolas Noiseux, Louis Mathieu Stevens, Ignacio Prieto, Fadi Basile, Joannie Dionne, Julie Fecteau, Eugene H. Blackstone, A. Marc Gillinov, Pamela Lackner, Leoma Berroteran, Diana Dolney, Suzanne Fleming, Roberta Palumbo, Christine Whitman, Kathy Sankovic, Denise Kosty Sweeney, Gregory Pattakos, Pamela A. Clarke, Michael Argenziano, Mathew Williams, Lyn Goldsmith, Craig R. Smith, Yoshifumi Naka, Allan Stewart, Allan Schwartz, Daniel Bell, Danielle Van Patten, Sowmya Sreekanth, John H. Alexander, Carmelo A. Milano, Donald D. Glower, Joseph P. Mathew, J. Kevin Harrison, Stacey Welsh, Mark F. Berry, Cyrus J. Parsa, Betty C. Tong, Judson B. Williams, T. Bruce Ferguson, Alan P. Kypson, Evelio Rodriguez, Malissa Harris, Brenda Akers, Allison O'Neal, John D. Puskas, Robert Guyton, Jefferson Baer, Kim Baio, Alexis A. Neill, Mario Senechal, François Dagenais, Kim O'Connor, Gladys Dussault, Tatiana Ballivian, Suzanne Keilani, Alan M. Speir, Patrick Magee, Niv Ad, Sally Keyte, Minh Dang, Mark Slaughter, Marsha Headlee, Heather Moody, Naresh Solankhi, Emma Birks, Mark A. Groh, Leslie E. Shell, Stephanie A. Shepard, Benjamin H. Trichon, Tracy Nanney, Lynne C. Hampton, David A. D'Alessandro, Joseph J. DeRose, Daniel J. Goldstein, Ricardo Bello, William Jakobleff, Mario Garcia, Cynthia Taub, Daniel Spevak, Roger Swayze, Arsène Joseph Basmadjian, Denis Bouchard, Michel Carrier, Raymond Cartier, Michel Pellerin, Jean François Tanguay, Ismail El-Hamamsy, André Denault, Philippe Demers, Sophie Robichaud, Keith A. Horvath, Philip C. Corcoran, Michael P. Siegenthaler, Mandy Murphy, Ann Greenberg, Chittoor Sai-Sudhakar, Ayseha Hasan, Asia McDavid, Bradley Kinn, Pierre Pagé, Carole Sirois, David Latter, Howard Leong-Poi, Daniel Bonneau, Lee Errett, Mark D. Peterson, Subodh Verma, Randi Feder-Elituv, Gideon Cohen, Campbell Joyner, Stephen E. Fremes, Fuad Moussa, George Christakis, Reena Karkhanis, Terry Yau, Michael Farkouh, Anna Woo, Robert James Cusimano, Tirone David, Christopher Feindel, Lisa Garrard, Suzanne Fredericks, Amelia Mociornita, John C. Mullen, Jonathan Choy, Steven Meyer, Emily Kuurstra, Cindi A. Young, Dana Beach, Pavan Atluri, Y. Joseph Woo, Mary Lou Mayer, Michael Bowdish, Vaughn A. Starnes, David Shavalle, Ray Matthews, Shadi Javadifar, Linda Romar, Irving L. Kron, Karen Johnston, John M. Dent, John Kern, Jessica Keim, Sandra Burks, Kim Gahring, David A. Bull, Patrice Desvigne-Nickens, Dennis O. Dixon, Mark Haigney, Richard Holubkov, Alice Jacobs, Frank Miller, John M. Murkin, John Spertus, Andrew S. Wechsler, Frank Sellke, Cheryl L. McDonald, Robert Byington, Neal Dickert, John S. Ikonomidis, David O. Williams, Clyde W. Yancy, James C. Fang, Nadia Giannetti, Wayne Richenbacher, Vivek Rao, Karen L. Furie, Rachel Miller, Sean Pinney, William C. Roberts, Mary N. Walsh, Stephen J. Keteyian, Clinton A. Brawner, Heather Aldred, Judy Hung, Xin Zeng, Jeffrey Browndyke, Yanne Toulgoat-Dubois

Research output: Contribution to journalArticlepeer-review

6 Scopus citations


Objective: The Cardiothoracic Surgical Trials Network reported that left ventricular reverse remodeling at 2 years did not differ between patients with moderate ischemic mitral regurgitation randomized to coronary artery bypass grafting plus mitral valve repair (n = 150) or coronary artery bypass grafting alone (n = 151). To address health resource use implications, we compared costs and quality-adjusted survival. Methods: We used individual patient data from the Cardiothoracic Surgical Trials Network trial on survival, hospitalizations, quality of life, and US hospitalization costs to estimate cumulative costs and quality-adjusted life years. A microsimulation model was developed to extrapolate to 10 years. Bootstrap and deterministic sensitivity analyses were performed to address uncertainty. Results: In-hospital costs were $59,745 for coronary artery bypass grafting plus mitral valve repair versus $51,326 for coronary artery bypass grafting alone (difference $8419; 95% uncertainty interval, 2259-18,757). Two-year costs were $81,263 versus $67,341 (difference 13,922 [2370 to 28,888]), and quality-adjusted life years were 1.35 versus 1.30 (difference 0.05; −0.04 to 0.14), resulting in an incremental cost-effectiveness ratio of $308,343/quality-adjusted life year for coronary artery bypass grafting plus mitral valve repair. At 10 years, its costs remained higher ($107,733 vs $88,583, difference 19,150 [−3866 to 56,826]) and quality-adjusted life years showed no difference (−0.92 to 0.87), with 5.08 versus 5.08. The likelihood that coronary artery bypass grafting plus mitral valve repair would be considered cost-effective at 10 years based on a cost-effectiveness threshold of $100K/quality-adjusted life year did not exceed 37%. Only when this procedure reduces the death rate by a relative 5% will the incremental cost-effectiveness ratio fall below $100K/quality-adjusted life year. Conclusions: The addition of mitral valve repair to coronary artery bypass grafting for patients with moderate ischemic mitral regurgitation is unlikely to be cost-effective. Only if late mortality benefits can be demonstrated will it meet commonly used cost-effectiveness criteria.

Original languageEnglish
Pages (from-to)2230-2240.e15
JournalJournal of Thoracic and Cardiovascular Surgery
Issue number6
StatePublished - Jun 2020

Bibliographical note

Funding Information:
The CTSN moderate ischemic MR trial 6,7 was funded by the National Institutes of Health and the Canadian Institutes of Health Research and conducted at 26 clinical centers. A total of 301 patients with multivessel coronary artery disease and moderate ischemic MR were randomized between 2009 and 2013 to undergo CABG alone (n = 151) or CABG plus MV repair (n = 150). CABG was performed on-pump using standard techniques, and all patients received guideline-directed medical therapy. In patients randomized to CABG plus MV repair, a rigid or semi-rigid complete annuloplasty ring was used. The ring was downsized by 2 sizes when possible to correct for annular dilatation. The specific ring type, implantation technique, and myocardial preservation method were at the surgeon's discretion. Causes of death and adverse events were adjudicated by an independent committee of experts. A National Institutes of Health–appointed data and safety monitoring board oversaw trial progress.

Funding Information:
This work was supported by a cooperative agreement (U01 HL088942) funded by the National Heart, Lung, and Blood Institute and the National Institute of Neurological Disorders and Stroke of the National Institutes of Health and the Canadian Institutes of Health Research. B.S.F. was supported by American Heart Association Grant #16MCPRP31030016 (to Dr Ferket). The views expressed in this article are those of the authors and do not necessarily represent the views of the National Heart, Lung, and Blood Institute; National Institutes of Health; or the US Department of Health and Human Services.

Publisher Copyright:
© 2019 The American Association for Thoracic Surgery


  • CABG
  • Cardiothoracic Surgical Trials Network
  • cost-effectiveness analysis
  • health care costs
  • ischemic mitral regurgitation
  • mitral valve
  • mitral valve repair
  • quality-adjusted life years

ASJC Scopus subject areas

  • Surgery
  • Pulmonary and Respiratory Medicine
  • Cardiology and Cardiovascular Medicine


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