Decision analysis to define the optimal management of athletes with anomalous aortic origin of a coronary artery

• Published in: The Journal of thoracic and cardiovascular surgery Vol. 152; no. 5; pp. 1366 - 1375.e7
• Main Authors: Mery, Carlos M., MD, MPH, Lopez, Keila N., MD, MPH, Molossi, Silvana, MD, PhD, Sexson-Tejtel, S. Kristen, MD, PhD, Krishnamurthy, Rajesh, MD, McKenzie, E. Dean, MD, Fraser, Charles D., MD, Cantor, Scott B., PhD
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.11.2016
• Subjects: Adolescent; Adult; Aged; anomalous aortic origin of a coronary artery; Athletes; Cardiothoracic Surgery; Child; coronary anomaly; coronary disease; Coronary Vessel Anomalies - physiopathology; Coronary Vessel Anomalies - surgery; decision analysis; Decision Support Techniques; exercise restriction; Female; Humans; Male; Middle Aged; Risk Factors; sudden cardiac death; surgery; anomalous aortic origin of a coronary artery; CI; decision analysis; coronary anomaly; exercise restriction; sudden cardiac death; quality-adjusted life year; coronary disease; ARCA; anomalous right coronary artery from the opposite sinus of Valsalva; anomalous left coronary artery from the opposite sinus of Valsalva; SCD; ALCA; QALY; confidence interval; surgery; AAOCA
• ISSN: 0022-5223; 1097-685X
• DOI: 10.1016/j.jtcvs.2016.07.076

Abstract Objectives The goal of this study was to use decision analysis to evaluate the impact of varying uncertainties on the outcomes of patients with anomalous aortic origin of a coronary artery. Methods Two separate decision analysis models were created: one for anomalous left coronary artery (ALCA) and one for anomalous right coronary artery (ARCA). Three strategies were compared: observation, exercise restriction, and surgery. Probabilities and health utilities were estimated on the basis of existing literature. Deterministic and probabilistic sensitivity analyses were performed. Results Surgery was the optimal management strategy for patients <30 years of age with ALCA. As age increased, observation became an equivalent strategy and eventually surpassed surgery as the treatment of choice. The advantage on life expectancy for surgery over observation ranged from 2.6 ± 1.7 years for a 10-year-old patient to −0.03 ± 0.1 for a 65-year old patient. In patients with ARCA, observation was the optimal strategy for most patients with a life expectancy advantage over surgery of 0.1 ± 0.1 years to 0.2 ± 0.4 years, depending on age. Surgery was the preferred strategy only for patients <25 years of age when the perceived risk of sudden cardiac death was high and the perioperative mortality was low. Exercise restriction was a suboptimal strategy for both ALCA and ARCA in all scenarios. Conclusions The optimal management in anomalous aortic origin of a coronary artery depends on multiple factors, including individual patient characteristics. Decision analysis provides a tool to understand how these characteristics affect the outcomes with each management strategy and thus may aid in the decision making process for a particular patient.