Aims:
The aim of this study is to observe long-term survival after MC therapy in high-risk patients with multiple cardiac interventions and to demonstrate the total costs of cardiovascular procedures as well as the changing costs over time and to explore the role of the cardiac related economic impact on overall survival.
Methods and Results:
Overall, 152 patients, who underwent MC and received either before or after the MC additional complex cardiovascular procedures were analyzed. A cost estimate of the cardiological procedures and their hospitalization costs were made according to the DRG (diagnosis-related group) catalog. Cardiac procedures included were MC, transcatheter aortic valve implantation (TAVI), occlusion of the left atrial appendage (LAA occlusion), electrophysiology study with catheter ablation, defibrillator implantation, cardiac resynchronization therapy (CRT) and cardiothoracic surgery. Calculations were made on the assumption that an average length of stay in the hospital was adhered to. All patients had severe symptomatic mitral valve regurgitation before the procedure, and 99.3% of patients reported exertional dyspnea of at least NYHA III prior to MC. The majority of patients had functional MR (60.5%), 23% had degenerative MR, and a mixed disease was documented in 16.5%. Our patients showed a poor overall left and right ventricular function and had multiple noncardiac comorbidities, e.g., chronic renal failure (stage ≥ 3, 64.5%), COPD (42.1%) and anemia (67.8%). Median duration of investigation from the first complex cardiac procedure until the end of the follow-up was 5.7 years (IQR 2.3-12.3) and median follow-up time after MC was 1.7 years (IQR 1.0-2.3). MC intrahospital mortality was 6.6% and follow-up mortality was 31.5%. Taking into account all prior procedures, the MC procedure and all follow-up interventions the median total cost of all the cardiovascular hospital stays was € 63,270 (IQR 52,282-74,005). Median pre-MC cardiovascular procedural costs were 21,274 € (IQR 14,528-32,606) and post-MC 2,845 (IQR 0-11,332) (p < 0,0001). Annualized pre-MC costs were € 5,991 (IQR 2,448-20,003) and post-MC € 3,270 (IQR 0-9,382) (p = 0.017). Follow-up survivors had a lower average annualized post-MC cost compared to non-survivors; however, the difference was not statistically significant (p = 0.5). Neither the cumulative costs nor the total number of cardiovascular interventions were associated with a higher mortality rate (p = 0.13 and p = 0.22 respectively). In the Cox regression analysis, only the hematocrit value and the GFR could be identified as independent predictors for long-term survival (p = 0.018 and p = 0.006).
Conclusion:
MitraClip Therapy is shown to reduce the total and annualized cardiovascular economic burden of high-risk patients with multiple comorbidities. The amount of cumulative cardiac related costs as well as the number of cardiovascular procedures performed was not associated with a worse long-term outcome. The pre-procedural hematocrit and the GFR were identified as the only independent predictors for long-term survival after MC.
Keywords: MitraClip, mitral regurgitation, high-risk patients, economic burden, annualized costs