Balloon angioplasty is preferred to surgery for aortic coarctation
Derek Wong1, Lee N Benson, Glen S Van Arsdell
1Division of Cardiology, Department of Pediatrics, University of Toronto, The Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada.
Insights
Balloon angioplasty is preferred over surgery for treating aortic coarctation in children. This analysis considered outcomes and patient preferences, favoring angioplasty in most cases.
Area of Science:
- Pediatric cardiology
- Interventional cardiology
- Decision analysis in medicine
Background:
- Aortic coarctation treatment involves surgery or balloon angioplasty.
- Outcomes and complications differ between these interventions, complicating direct comparison.
Purpose of the Study:
- To compare patient and medical professional preferences for balloon angioplasty versus surgery in treating pediatric aortic coarctation.
- To utilize decision analysis techniques to quantify the value of each treatment option.
Main Methods:
- Decision trees were formulated using probabilities of treatment success, complications, recoarctation, and aneurysm from 1984-2005 literature.
- Medical professionals' preferences for various outcomes were determined via standard gamble interviews.
- Preference scores were adjusted for mortality and procedural disutility, with sensitivity analyses performed.
Main Results:
- Balloon angioplasty (mean score 0.8999) was significantly preferred over surgery (mean score 0.8873).
- This preference held even when adjusting for mortality and disutility.
- Angioplasty remained preferred unless surgical mortality was <4% in neonates; angioplasty complications would need to be implausibly high for surgery to be favored.
Conclusions:
- Balloon angioplasty is the preferred initial treatment for native aortic coarctation in children.
- This preference is robust across various outcome probabilities and patient preferences.
- Decision analysis provides a framework for comparing complex treatment options with differing outcomes.
Objective:
We sought to use techniques of decision analysis to compare values or preferences for balloon angioplasty versus surgery for treatment of aortic coarctation in children.
Background:
Balloon angioplasty and surgery for aortic coarctation have a differing spectrum and prevalence of outcomes and complications, making direct comparison difficult.
Methods:
From articles reporting treatment outcomes of native aortic coarctation from 1984 through 2005, we determined the baseline probabilities of successful treatment, complications, recoarctation and aneurysmal formation. Decision trees with baseline probabilities of these outcomes were formulated. Standard gamble interviews of medical professionals determined the preferences for the various outcomes. Final cumulative preference scores were further adjusted for both perceived mortality and procedural disutility. Sensitivity analyses determined threshold probabilities at which the score advantage changed.
Results:
Final preference scores for balloon angioplasty, with a mean of 0.8999, and standard deviation of 0.0236, were significantly higher than for surgery, at a mean of 0.8873, and standard deviation of 0.0246. The score advantage for balloon angioplasty did not change when adjusted for disutility, or mortality. Sensitivity analysis showed that even if the probability of periprocedural death or major complications for surgery was reduced to none, balloon angioplasty would still be preferred, expect for neonates, where if surgical mortality were reduced below 4%, then surgery would be preferred. Probabilities for periprocedural death or major complications associated with balloon angioplasty would have to exceed plausible thresholds before surgery would be preferred.
Conclusions:
After accounting for preference-weighted probabilities of outcomes, balloon angioplasty is preferred over surgery for all plausible situations as the initial treatment for native aortic coarctation in children.
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