Quality of life and economic outcomes with surgical ventricular reconstruction in ischemic heart failure: results from the Surgical Treatment for Ischemic Heart Failure trial

Abstract

Background: Surgical ventricular reconstruction (SVR) is used in conjunction with coronary artery bypass graft surgery (CABG) to improve left ventricular function and clinical outcomes in selected patients with ischemic heart failure. The impact of SVR on quality of life (QOL) and medical costs is unknown.

Methods: We compared CABG plus SVR with CABG alone in 1,000 patients with ischemic heart failure, an anterior wall scar, and a left ventricular ejection fraction <or=0.35. In 991 (99% of eligible), we collected a battery of QOL instruments. The principal, prespecified QOL measure was the Kansas City Cardiomyopathy Questionnaire, which evaluates the effects of heart failure symptoms on QOL using a scale from 0 to 100 with higher scores indicating better QOL. Structured QOL interviews were conducted at baseline, 4, 12, 24, and 36 months post randomization and were >or=92% complete. Cost data were collected on 196 (98%) of 200 patients enrolled in the United States.

Results: Heart-failure-related QOL outcomes did not differ between the 2 treatment strategies out to 3 years (median Kansas City Cardiomyopathy Questionnaire scores for CABG alone and CABG plus SVR, respectively: baseline 53 versus 54, P = .53; 3 years 85 versus 84, P = .89). There were no treatment-related differences in other QOL measures. In the US patients, total index hospitalization costs averaged over $14,500 higher for CABG plus SVR (P = .004) due primarily to 4.2 extra postoperative, high-intensity care days in the hospital.

Conclusions: Addition of SVR to CABG in patients with ischemic heart failure did not improve QOL but significantly increased health care costs.

Trial registration: ClinicalTrials.gov NCT00023595.

Figure 1

This figure shows the rate of QOL data collection at each point in follow-up and reasons for missing data.

Figure 2

A box and whisker plot of the distribution of total index hospitalization costs for the 196 U.S. patients with cost data. Diamond symbol is mean, central bar is median, top and bottom of box are 75^th and 25^th percentiles respectively. Error bars represent the minimum and maximum, and the plot truncates the baseline costs at $200,000. Two patients in the CABG-plus-SVR group and one patient in the CABG-only group were above this figure. The plot shows that the entire distribution of costs for the CABG-plus-SVR arm is shifted up (toward higher cost) relative to the CABG-alone arm indicating that the difference between the two arms is not driven by a small proportion of outlier values.