A cost comparison of heart transplantation versus alternative operations for cardiomyopathy

Background. Heart transplantation is an established therapy for cardiomyopathy but is limited by organ shortage and expense. As a result, alternative operations have been proposed including coronary bypass, mitral valve repair, and left ventricular reconstruction. Because it is unknown whether alternative operations are less expensive than replacing the diseased heart, we compared in-hospital costs and early outcome of these operations with elective heart transplantation. Methods. We compared clinical and financial data of 268 patients with ejection fraction less than 30% who underwent elective heart transplantation (n=52, UNOS status 2 only), coronary bypass (n=176), mitral repair (n=15), or left ventricular reconstruction (n=25). Data were evaluated for between-group differences, with p less than 0.05 as significant. Results. Preoperative ejection fraction, although similar for heart transplantation (21.2%±1.3%), coronary bypass (25.8%±0.4%), mitral repair (22.9%±1.5%), and left ventricular reconstruction (24.2%±2.1%), was significantly different between the former two (p<0.001). There was no difference in operative mortality: 5.8% (3 of 52), 3.4%(7 of 176), 6.7% (1 of 15), and 4.0% (1 of 25), respectively (p=0.8). However, total hospital cost of heart transplantation was significantly greater than all others: $75,992±$5,380, $25,008±$1,446, $32,375±$2,379, and $26,584±$4,076, respectively (p<0.001). Organ procurement expenses alone comprised 39.7% ($30,169) of total transplant cost. Kaplan-Meier survival analysis failed to show any survival difference between the various groups (p=0.86). Conclusions. Compared with heart transplantation, alternative operations yield a comparable early outcome and long-term survival, and are markedly less expensive. The cost of transplantation, which is largely due to procurement expenses, is yet another reason to attempt alternative operations for cardiomyopathy whenever feasible.