Purpose: Cardiac allograft vasculopathy (CAV) is a leading cause of long-term mortality after pediatric heart transplantation. The gold standard of diagnosis is coronary angiography, an invasive procedure with risks of adverse events, radiation exposure, and high cost. We evaluated the effectiveness and costs of an alternative modality of diagnosing CAV using two models: 1) yearly dobutamine stress echocardiography (DSE) screening followed by confirmatory angiography and 2) yearly coronary angiography alone.

Methods: A Markov model was used to determine the incremental cost per diagnosis of CAV made via yearly angiography alone, compared with yearly DSE screening with confirmatory angiography. A hypothetical cohort of 1,000 children having undergone transplant was followed over 15 years. Probabilities of CAV development and mortality were derived from 2014 ISHLT transplant mortality/morbidity data across all ages of transplant. Test characteristics were found in the existing literature on DSE screening, and costs (2014 US$) were derived from Medicare data. Outcomes included number of CAV diagnoses made, numbers of angiographies performed, and total costs. Sensitivity analyses were performed on key inputs.

Results: At 15 years, the model predicted 49% mortality and 48% development of CAV in this hypothetical population, approximating current estimates for transplant outcomes. The yearly angiography arm made 388 correct CAV diagnoses at a total cost of $6,641,307, as compared to the DSE screening model making 361 correct CAV diagnoses at a total cost of $3,331,792. In addition, the DSE screening approach resulted in fewer angiographies being performed (1,242 versus 8,527 in the yearly angiography arm). The yearly angiography approach made 27 more diagnoses at a cost of $3,309,515, for an incremental cost-effectiveness ratio (ICER) of $122,574 per each additional correct diagnosis.

Conclusion: DSE screening in children may be a reasonable approach for diagnosing CAV, capturing 93% of the cases found by annual angiography over 15 years in this predictive model. Yearly angiography costs more than $120,000 for each additional diagnosis not found by DSE screening. Further study is needed to determine the optimal cost-effective approach to diagnosing CAV in pediatric patients.

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