Cost-effectiveness of radiofrequency ablation compared with other strategies in Wolff-Parkinson-White syndrome

BACKGROUND

Patients with Wolff-Parkinson-White syndrome fall into four risk groups: those with (1) prior cardiac arrest, (2) paroxysmal supraventricular tachycardia or atrial fibrillation (PSVT/AF) with hemodynamic compromise, (3) PSVT/AF without hemodynamic compromise, and (4) no symptoms.

METHODS AND RESULTS

For each group, we developed a cost-effectiveness analysis examining five clinical management strategies: (1) observation, (2) observation until a cardiac arrest dictates the need for therapy, (3) initial drug therapy guided by noninvasive monitoring, (4) initial radiofrequency ablation (RFA), and (5) initial surgical ablation. We used a Markov simulation model to estimate life expectancy and costs for patients whose ages are between 20 and 60 years. The model includes the risks of cardiac arrest, PSVT/AF, drug side effects, procedure-related complications and mortality, the efficacy of drugs and RFA, and costs. Based on literature and expert opinion, we assumed that the annual risks of cardiac arrest are 0.01%, 0.05%, and 0.5%, respectively, in patients who are asymptomatic, who had PSVT/AF without hemodynamic compromise, or who had PSVT/AF with hemodynamic compromise. We also assumed that RFA has an overall efficacy of 92% in preventing cardiac arrest and arrhythmias. Our model predicts that RFA should yield a life expectancy greater than or equal to other strategies. In cardiac arrest survivors and patients who have had PSVT/AF with hemodynamic compromise, our model suggests that RFA should both prolong survival and save resources. For patients with PSVT/AF without hemodynamic compromise, the marginal cost-effectiveness of attempted RFA (followed by conservative treatment if the RFA fails) ranges from $6600 per quality-adjusted life year (QALY) gained for 20-year-old patients to $19,000 per QALY gained for 60-year-old patients. For asymptomatic patients, RFA costs from $174,000 per QALY gained for 20-year-old patients to $540,000 per QALY gained for 60-year-old patients.

CONCLUSIONS

Our analysis supports the emerging practice of performing RFA in patients with Wolff-Parkinson-White syndrome who survive cardiac arrest or who experience PSVT/AF but also supports the current practice of observing asymptomatic patients.

Repeated use of ablation catheters: a prospective study

OBJECTIVES

The objective of this study was to provide insight into the time course of electrical, physical and mechanical changes in ablation catheters after each use that may affect the safety and efficacy of the ablation procedure.

BACKGROUND

An increasing number of institutions are reusing deflectable ablation catheters. At present, there are no data concerning the safety of reusing ablation catheters.

METHODS

Over a period of 1 year, 69 Webster/Mansfield deflectable catheters used in 336 ablation procedures were prospectively studied. An additional 18 new catheters were tested after multiple sterilizations only. The catheters were evaluated for electrical and physical integrity and mechanical capabilities. These include deflection at room temperature and 37 degrees C, shaft compression and buckling during deflection, tip craters, torquing ability, glue separation and tip attachment using a stereoscope at x30 magnification and electrical resistance for each electrode. After each use, the catheters were gas-sterilized with ethylene oxide.

RESULTS

The most common reasons for catheter rejection were tip electrode glue separation after 4.3 +/- 4.3 uses and loss of deflection after 5.0 +/- 3.3 uses. Electrical discontinuity between the catheter handle and electrodes was observed after 10.0 +/- 3.7 uses. There was no significant decrease in catheter torquing ability with repeated use. In this study the total estimated savings was $128,133, which includes the cost of catheter reprocessing. The reuse of Webster/Mansfield ablation catheters has not resulted in any major catheter failure or any major adverse clinical complications.

CONCLUSIONS

On the basis of these observations, we believe that the Webster/Mansfield catheter can be reused an average of five times. It is strongly recommended that after each use catheters be carefully examined under appropriate magnification (x30) and that special attention be given to the ablation tip electrode. The catheters should also be tested for deflection and electrical integrity.

Cost effectiveness of radiofrequency catheter ablation in the treatment of symptomatic supraventricular tachyarrhythmias

BACKGROUND

The recent advent of radiofrequency (RF) catheter ablation as a curative therapy for supraventricular tachyarrhythmias has challenged the role of long term drug treatment, which is essentially a palliative therapy. To date, however, no data have been published on the cost-effectiveness of RF ablation as compared with drug treatment in the Australian setting.

AIMS

The study aimed to compare actual and projected costs of these two treatment options in a consecutive group of patients having RF ablation as treatment for symptomatic tachyarrhythmias.

METHODS

The cost effectiveness of RF catheter ablation was assessed in 26 patients having RF ablation, using a hypothetical model of continued drug therapy in the same group of patients. A 'cost saving' criterion was used for cost effectiveness. Actual costs for the RF ablation and for continued drug therapy were based on data from medical records and from the answers to a detailed patient questionnaire. Analysis included costs of prior diagnostic electrophysiology (EP) study (17/26 patients), general anaesthesia (GA: 20/26 patients), post-ablation echocardiography (10/26 patients), and late follow-up EP study (7/26 patients). The in-hospital stay for the RF ablation was two days in all cases, and no patient required implantation of a permanent pacemaker. The RF ablation procedure was successful in 23/26 patients (88.5%) with late recurrence of tachycardia in one patient. After a median follow-up of nine months, 22/26 patients no longer require antiarrhythmic drug therapy.

RESULTS

The mean per patient cost of RF ablation was $4067 in the study group. This reduces to $2546 if prior EP study and GA are excluded. The mean per patient cost of continued medical therapy was $700 per year. Extrapolating over 20 years and allowing for an annual 5% inflation factor, RF ablation becomes cost saving in 5.5 years (3.8 years if prior EP and GA are excluded). Over 20 years, continued drug therapy would be four to five times more expensive than RF ablation in the patient study group. We consider RF ablation to be a cost-effective alternative to long term drug therapy in patients with supraventricular tachyarrhythmias.

Financial audit of antitachycardia pacing for the control of recurrent supraventricular tachycardia

OBJECTIVE

To assess the financial implications of antitachycardia pacing in patients with frequent supraventricular tachycardia.

PATIENTS

Intertach pacemakers were implanted in 25 patients (mean age 47 years, five men): 22 had atrioventricular nodal reentry tachycardia. The patients had failed a mean of 4.9 (range zero to eight) drugs and had been admitted to hospital 3.7 (zero to 31) times over a symptomatic period of 13.9 years (two months to 54 years).

RESULTS

The mean admission time for implantation was 2.8 (two to seven) days. One patient with Wolff-Parkinson-White syndrome subsequently underwent surgery. Infection occurred in two patients, and pain over the pacemaker required its resiting in two. Two patients have had one admission each for tachycardia. Six patients remain on anti-arrhythmic drugs. Costs were calculated including value added tax, capital charges, and allocated overheads. The cost a year before pacing was 1174 pounds including drug costs, clinic visits, and hospital admissions. The mean cost of pacemaker implantation was 3364.22 pounds, including the pacemaker and lead, admission and procedure, readmissions and first pacing check. Subsequent annual follow up cost was 73.72 pounds including annual clinic visits and drug costs. The cost of pacing is 4241 pounds whereas medical management costs 7044 pounds assuming pacemaker life of six years: with a 10 year life the cost is 4537 pounds compared with 11,740 pounds: with a 12 year life the cost is 4685 pounds compared with 14,088 pounds.

CONCLUSION

The excess cost of implantation of an antitachycardia pacemaker is minimal in patients with frequent supraventricular tachycardia despite drug treatment and is justified by excellent control of symptoms and reduction of drug use and hospital admissions.

Safety, feasibility and cost of outpatient radiofrequency catheter ablation of accessory atrioventricular connections

OBJECTIVES

The purpose of this study was to evaluate prospectively the safety, feasibility and cost of performing radiofrequency catheter ablation of accessory atrioventricular (AV) connections on an outpatient basis in 137 cases.

BACKGROUND

The efficacy and low complication rate of radiofrequency ablation as performed in the hospital suggested that it might be feasible to perform it on an outpatient basis.

METHODS

In 100 cases (73%) performed between September 1, 1991 and April 20, 1992, patients met criteria for treatment as outpatients. Reasons for exclusion were age < 13 or > 70 years (4), anteroseptal location of the accessory AV connection (5 patients), obesity (> 30% of ideal body weight) (4 patients) or clinical indication for hospitalization (24 patients). Patients with only venous punctures had a recovery period of 3 h and those with arterial punctures had a recovery period of 6 h. There were 63 men and 32 women (5 patients underwent two ablation procedures > 1 month apart), with a mean age +/- SD of 36 +/- 13 years. The pathway was left-sided in 67 cases and right-sided or posteroseptal in 33.

RESULTS

The procedure was successful in 97 of 100 cases, with a mean procedure duration of 99 +/- 42 min. In 70 cases the patient was discharged the day of ablation, and in 30 cases the patient required a short (< or = 18-h) overnight stay because the procedure was completed too late in the day for recovery in the outpatient facility. The mean duration of observation was 4.8 +/- 1.5 h for outpatients and 15 +/- 1.4 h for patients who underwent overnight hospitalization. At follow-up study, two patients had a clinically significant complication; both had a femoral artery pseudoaneurysm detected > or = 1 week after the procedure and both required surgical repair. Thirty consecutive patients (22 outpatients and 8 hospitalized overnight) undergoing catheter ablation after January 1, 1992 were chosen for a cost analysis. The mean cost of the procedure was $10,183 +/- $1,082.

CONCLUSIONS

The majority of patients undergoing radiofrequency catheter ablation of an accessory AV connection can be treated safely on an outpatient basis.

Coronary rotational ablation: an overview with related nursing interventions

The treatment of coronary artery disease has changed significantly over the last decade. It is estimated that more than 300,000 percutaneous transluminal coronary angioplasty procedures were performed in 1990. Despite advances in angioplasty technique and increased immediate success rates, limitations to treatment remain and have prompted a continuing search for a more effective revascularization device. Rotational ablation performed with a high-speed burr covered with diamond microcrystals has been proven safe and effective in treating coronary lesions. At high speeds the burr preferentially ablates plaque. The particles produced during the procedure are smaller than red blood cells and are readily disposed of by the reticuloendothelial system. This article is an overview of the rotational ablation procedure and related nursing care of the patient.

Pharmacoeconomic considerations in antiarrhythmic therapy

Recently, the Cardiac Arrhythmia Suppression Trial (CAST) has focused attention on the morbidity and mortality that may be associated with pharmacological antiarrhythmic therapies. While the severity and frequency of adverse effects vary among the available agents, it is uncertain whether initial therapy with one agent is preferable to that with another when efficacy, incidence of adverse effects and costs of treating these adverse effects are examined. Moreover, it is uncertain whether pharmacotherapy is more cost-effective than other strategies.

Treatment of supraventricular tachycardias with transcatheter delivery of radiofrequency current

Medical therapy for the treatment of supraventricular tachycardias is frequently ineffective and associated with significant side effects, whereas curative surgical approaches have generally been limited by their considerable morbidity and cost. Greater understanding of the mechanisms underlying supraventricular tachycardias has improved our ability to precisely map endocardial areas critical to arrhythmogenesis. Advances in catheter ablation techniques and particularly the use of radiofrequency current to generate thermal energy for ablation have resulted in dramatic success rates for curative catheter ablation. This review examines the physics of radiofrequency current ablation and its application to the treatment of atrial fibrillation, atrial flutter, AV nodal reentrant tachycardia, and arrhythmias associated with the Wolff-Parkinson-White syndrome. The limitations, risks, and cost-effectiveness of this technique relative to medical and surgical approaches are also evaluated.