176 COST-EFPECTIVENESS OF PREOPERATIVE CATHETERIZATION IN INFANTS WITH D-TRANSPOSITION OF THE GREAT ARTERIES, INTACT VENTRICULAR SEPTUM

Abstract

We analyzed the need for routine cardiac catheterization (CC) prior to corrective surgery in infants age 6-12 mo. with d-transposition of the great arteries, intact ventricular septum (dTGA, IVS) , s/p balloon atrial septostomy in the neonatal period, who have at most a grade 2/6 murmur, small left ventricular forces on electrocardiogram, and no evidence of fixed subpulmonic stenosis (subPS) by echocardiogram or previous angiography. We compared mortality and costs among those undergoing preop CC with those proceeding directly to a baffle procedure. We assumed 1) that the frequency of the above clinical constellation among infants with severe subPS is 1%, among infants with pulmonary artery hypertension (PAH) is 25%, and among those with neither complication is 90%; 2) that the frequency of severe fixed subPS is 5% and of PAH is 2%; 3) that the mortality from CC is 0.1%, from the baffle procedure in uncomplicated dTGA,IVS, 5%, from baffle procedure with subpulmonic resection, 15%, and from baffle procedure without subpulmonic resection in infants with severe subPS, 100%. On these premises, the policy of routine CC carries an excess mortality (0.4/1000) when compared with the policy of operating without CC. Even if the frequency of severe subPS were as high as 10%, the cost of averting one death by the policy of routine preop CC would be $5-10 million. Thus routine preop CC may not be warranted in this clinical setting.