ABSTRACT
Background: Inverted left atrial appendage (ILAA) is a rare condition following cardiac surgery. Failure to recognize the condition or making misdiagnosis of a tumour, a thrombus or vegetation can lead to unnecessary and potentially adverse events. We present a case of ILAA after surgical repair of an atrial septal defect (ASD) in a young female. Case summary: A 3-year-old caucasian female was admitted for surgical repair of an ASD. The intraoperative course was uneventful until the opening of the right atrium (RA) after the commencement of cardiopulmonary bypass (CPB) and vacuum application, where the inferior vena cava (IVC) cannula was seen displaced in the RA. Cannula was repositioned, and ASD was repaired. On post-CPB transesohageal echocardiography (TEE), a newly developed mass was revealed in the left atrium (LA). The heart was re-arrested, and LA was re-assessed with unexpected finding of ILAA. ILAA was everted. RA was closed and CPB weaned off. Repeated post-CPB TEE showed no mass in the LA. No recurrence of mass was demonstrated on follow-up transthoracic echocardiography (TTE). Discussion: The incidence of ILAA is rare. Therefore, it is usually forgotten and not anticipated as a complication during heart surgery using CPB. In our case, dislodgement of the IVC cannula into the RA in combination with vacuum application in the setting of an ASD may have resulted in ILAA. This has not been reported in previous cases. ILAA should be suspected on intraoperative TEE if the mass is newly developed. Visual inspection of the left atrium appendage (LAA) in situ is recommended before chest closure.
ABSTRACT
AIMS: The aim of this study was to estimate the cost-effectiveness of transcatheter aortic valve implantation (TAVI) versus surgical aortic valve replacement (SAVR) in patients at lower surgical risk. METHODS AND RESULTS: Discounted costs from a societal perspective and effectiveness as quality-adjusted life years (QALYs) were projected to lifetime via a decision-analytic model calibrated to 60-month data from the NOTION trial. The base case assumed a scenario in which any mortality benefit would gradually fade out over time, with other scenarios explored in sensitivity analyses. The incremental cost-effectiveness ratio (ICER) was compared to the country-specific willingness-to-pay (WTP) threshold of 1.13 million Danish kroner (DKK). The base case ICER was DKK 696,264/QALY (around 72,100/QALY via purchasing parity adjustment). Variation in long-term mortality beyond five years led to limited variation of incremental costs (DKK 64,200 to 64,600), but a more pronounced variation in incremental QALYs (0.07 to 0.19 QALYs for most conservative and optimistic assumptions, compared to base case of 0.09 QALYs). All resulting ICERs (range DKK 334,200 to DKK 904,100 per QALY gained) were below the WTP threshold. CONCLUSIONS: TAVI in a cohort of primarily low surgical risk patients was found to be a cost-effective treatment strategy in the Danish healthcare system. Cost-effectiveness analyses in other settings are warranted as are registries given the sensitivity of the model to long-term mortality.
