Decision analytic investigations comparing balloon aortic valvuloplasty and surgical valvotomy in neonates with isolated critical aortic stenosis

Background: Despite limited comparative data, balloon aortic valvuloplasty (BAV) is used preferentially over surgical aortic valvotomy (SAV) for neonates with isolated critical aortic stenosis. We aimed to evaluate the cost-effectiveness of each intervention using a decision analytic framework. Methods: A cost-effectiveness analysis was constructed using a Markov decision analytic model with 1-year cycles on a 20-year horizon. Two simulated cohorts of 10,000 neonates underwent either BAV or SAV. Outcomes included survival, aortic valve reintervention, aortic valve replacement (AVR), and death. Costs reflected hospitalization-related expenditures inflation-adjusted to January 2024 US dollars. Effectiveness was defined as the years that each patient remained alive with their native aortic valve. Comparisons were established considering net monetary benefit and the incremental cost-effectiveness ratio (ICER). Sensitivity analysis assessed how input variation altered the net benefit of each strategy. Results: On the 20-year horizon, BAV was associated with higher cumulative mortality (14.95% vs 6.53%), more reinterventions (2.37 vs 1.95 per patient), and lower cumulative cost ($111,243 vs $175,415) compared to SAV. The mean age at AVR was similar in the 2 groups (12.69 ± 7.67 years for BAV and 12.64 ± 7.65 years for SAV). At baseline, BAV dominated SAV, with an ICER of $1,305,793 per year for remaining alive with a native aortic valve. Sensitivity analysis identified the main drivers of this as high SAV cost, high early SAV mortality, and low early BAV mortality. Should these values be reduced, the model would favor SAV. Conclusions: This computational investigation provides a framework for validating current practice and highlights key variables to consider on a center-specific basis when managing neonates with critical aortic valve stenosis.