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Zhang H, Zhang H, Lu H, Mao Y, Chen J. Meta-analysis of pulsed-field ablation versus cryoablation for atrial fibrillation. Pacing Clin Electrophysiol 2024; 47:603-613. [PMID: 38525525 DOI: 10.1111/pace.14971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 02/28/2024] [Accepted: 03/07/2024] [Indexed: 03/26/2024]
Abstract
PURPOSE The available data on the treatment strategy of pulsed field ablation (PFA) for patients with atrial fibrillation (AF) is limited. This study aims to provide a comparative analysis of the efficacy, safety, and procedural efficiency between PFA and cryoballoon ablation (CBA) for AF. METHODS We conducted a comprehensive search of the EMBASE, PubMed, Cochrane Library, and ClinicalTrials.gov databases to identify trials comparing PFA with CBA for AF from their inception until December 2023. The odds ratio (OR) and mean difference (MD), along with a 95% confidence interval (CI), were utilized as measures of treatment effect. RESULTS The analysis included 15 eligible trials with a total enrollment of 1880 patients. No significant differences were found in recurrent atrial arrhythmia (OR 0.83, 95% CI 0.64, 1.07) or periprocedural complications (OR 0.78, 95% CI 0.46, 1.30) between the two ablation techniques examined in this study. However, the PFA technique demonstrated a significantly shorter procedure time (MD -7.17, 95% CI -13.60, -0.73), but a longer fluoroscopy time (MD 2.53, 95% CI 0.87, 4.19). Similarly, PFA was found to be significantly associated with a decreased incidence of phrenic nerve palsy (OR 0.20, 95% CI 0.07, 0.59), but an increased incidence of cardiac tamponade (OR 4.07, 95% CI 1.15, 14.39). Moreover, there was a significantly higher release of troponin with PFA compared to CBA (MD 470.28, 95% CI 18.89, 921.67), while the increase in S100 protein and heart rate was significantly lower with PFA than with CBA (MD -64.41, 95% CI -105.46, -17.36), (MD -8.76, 95% CI -15.12, -2.40). CONCLUSION The utilization of PFA provides a safer, time-saving, and tissue-specific procedure compared to CBA, while maintaining comparable success rates. This has the potential to enhance procedural efficiency and optimize resource utilization in clinical practice. These findings underscore the feasibility and promise of PFA as an alternative technique for PVI in patients with AF.
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Affiliation(s)
- Hehua Zhang
- Department of Anesthesiology, Ninghua County General Hospital, Sanming, China
| | - Hua Zhang
- Department of Cardiovascular Surgery Nursing, Fujian Medical University Union Hospital, Fuzhou, China
| | - Heng Lu
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, China
| | - Yinjun Mao
- Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Jianxing Chen
- Department of Anesthesiology, the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of Anesthesiology, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1-e156. [PMID: 38033089 PMCID: PMC11095842 DOI: 10.1161/cir.0000000000001193] [Citation(s) in RCA: 286] [Impact Index Per Article: 286.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines liaison
| | | | | | | | | | - Paul L Hess
- ACC/AHA Joint Committee on Performance Measures liaison
| | | | | | | | | | - Kazuhiko Kido
- American College of Clinical Pharmacy representative
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3
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024; 83:109-279. [PMID: 38043043 PMCID: PMC11104284 DOI: 10.1016/j.jacc.2023.08.017] [Citation(s) in RCA: 95] [Impact Index Per Article: 95.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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4
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Schwennesen HT, Andrade JG, Wood KA, Piccini JP. Ablation to Reduce Atrial Fibrillation Burden and Improve Outcomes: JACC Review Topic of the Week. J Am Coll Cardiol 2023; 82:1039-1050. [PMID: 37648353 PMCID: PMC11103629 DOI: 10.1016/j.jacc.2023.06.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 05/31/2023] [Accepted: 06/12/2023] [Indexed: 09/01/2023]
Abstract
Atrial fibrillation is the most common atrial arrhythmia and accounts for a significant burden of cardiovascular disease globally. With advances in implanted and wearable cardiac monitoring technology, it is now possible to readily and accurately quantify an individual's time spent in atrial fibrillation. This review summarizes the relationship between atrial fibrillation burden and adverse cardiovascular and cerebrovascular outcomes and discusses the role of catheter ablation to mitigate the morbidity and mortality associated with greater burden of atrial fibrillation.
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Affiliation(s)
- Hannah T Schwennesen
- Cardiac Electrophysiology Section, Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Jason G Andrade
- Montreal Heart Institute, Department of Medicine, Université de Montréal, Montréal, Québec, Canada
| | - Kathryn A Wood
- Emory University, Nell Hodgson Woodruff School of Nursing, Atlanta, Georgia, USA
| | - Jonathan P Piccini
- Cardiac Electrophysiology Section, Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA; Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA; Department of Population Health Sciences, Duke University, Durham, North Carolina, USA.
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5
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Verma A, Haines DE, Boersma LV, Sood N, Natale A, Marchlinski FE, Calkins H, Sanders P, Packer DL, Kuck KH, Hindricks G, Tada H, Hoyt RH, Irwin JM, Andrade J, Cerkvenik J, Selma J, DeLurgio DB. Influence of monitoring and atrial arrhythmia burden on quality of life and health care utilization in patients undergoing pulsed field ablation: A secondary analysis of the PULSED AF trial. Heart Rhythm 2023; 20:1238-1245. [PMID: 37211146 DOI: 10.1016/j.hrthm.2023.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 05/05/2023] [Accepted: 05/12/2023] [Indexed: 05/23/2023]
Abstract
BACKGROUND Freedom from atrial arrhythmia (AA) recurrence ≥30 seconds after pulsed field ablation (PFA) in patients with atrial fibrillation (AF) was reported in PULSED AF (Pulsed Field Ablation to Irreversibly Electroporate Tissue and Treat AF; ClinialTrials.gov Identifier: NCT04198701). AA burden may be a more clinically meaningful endpoint. OBJECTIVE The purpose of this study was to determine the influence of monitoring strategies on AA detection and AA burden association with quality of life (QoL) and health care utilization (HCU) after PFA. METHODS Patients underwent 24-hour Holter monitoring at 6 and 12 months and weekly, and symptomatic transtelephonic monitoring (TTM). AA burden post-blanking was calculated as the greater of (1) percentage of AA on total Holter time; or (2) percentage of weeks with ≥1 TTM with AA out of all weeks with ≥1 TTM. RESULTS Freedom from all AAs varied by >20% when differing monitoring strategies were used. PFA resulted in zero burden in 69.4% of paroxysmal atrial fibrillation (PAF) and 62.2% of persistent atrial fibrillation (PsAF) patients. Median burden was low (<9%). Most PAF and PsAF patients had ≤1 week of AA detection on TTM (82.6% and 75.4%) and <30 minutes of AA per day of Holter monitoring (96.5% and 89.6%), respectively. Only PAF patients with <10% AA burden averaged a clinically meaningful (>19 point) QoL improvement. PsAF patients experienced clinically meaningful QoL improvements irrespective of burden. Repeat ablations and cardioversions significantly increased with higher AA burden (P <.01). CONCLUSION The ≥30-second AA endpoint is dependent on the monitoring protocol used. PFA resulted in low AA burden for most patients, which was associated with clinically relevant improvement in QoL and reduced AA-related HCU.
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Affiliation(s)
- Atul Verma
- McGill University Health Centre, Montreal, Quebec, Canada.
| | | | - Lucas V Boersma
- St. Antonius Hospital, Nieuwegein and Amsterdam UMC, The Netherlands
| | - Nitesh Sood
- Southcoast Health Center, Fall River, Massachusetts
| | | | | | | | | | | | | | | | | | | | | | - Jason Andrade
- Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | | | - David B DeLurgio
- Emory Heart & Vascular Center at Saint Joseph's, Atlanta, Georgia
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6
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Jackson II LR, Friedman DJ, Francis DM, Maccioni S, Thomas VC, Coplan P, Khanna R, Wong C, Rahai N, Piccini JP. Race and Ethnic and Sex Differences in Rhythm Control Treatment of Incident Atrial Fibrillation. CLINICOECONOMICS AND OUTCOMES RESEARCH 2023; 15:387-395. [PMID: 37273820 PMCID: PMC10237629 DOI: 10.2147/ceor.s402344] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 05/16/2023] [Indexed: 06/06/2023] Open
Abstract
Background Atrial fibrillation (AF) is associated with considerable morbidity and mortality. Timely management and treatment is critical in alleviating AF disease burden. Variation in treatment by race and ethnic and sex could lead to inequities in health outcomes. Objective To identify racial and ethnic and sex differences in rhythm treatment for patients with incident AF. Methods Using 2010-2019 Optum Clinformatics database, an administrative claims data for commercially insured patients in the United States (US), incident AF patients ≥20 years old who were continuously enrolled 12-months pre- and post-index diagnosis were identified. Rhythm control treatment (ablation, antiarrhythmic drugs [AAD], and cardioversion) for AF were compared by patient race and ethnicity (Asian, Hispanic, Black vs White) and sex (female vs male). Multivariable regression analysis was used to examine the relationship of race and ethnicity and sex with rhythm control AF treatment. Results A total of 77,932 patients were identified with incident AF. Black and Hispanic female patients had the highest CHA2DS2VASc scores (4.3 ± 1.8) and Elixhauser scores (4.1 ± 2.8 and 4.0 ± 6.7), respectively. Black males were less likely to receive AAD treatment (adjusted odds ratio [aOR] 0.87; 95% confidence interval [CI], 0.79-0.96) or ablation (aOR, 0.72; 95% CI, 0.58-0.90). Compared to White males, all groups had lower likelihood of receiving cardioversion with Asian females having the lowest [aOR, 0.48; 95% CI, (0.37-0.63)]. Conclusion Black patients were less likely to receive pharmacologic and procedural rhythm control therapies. Further research is needed to understand the drivers of undertreatment among racial and ethnic groups and females with AF.
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Affiliation(s)
- Larry R Jackson II
- Division of Cardiology, Duke University Medical Center & Duke Clinical Research Institute, Durham, NC, USA
| | - Daniel J Friedman
- Division of Cardiology, Duke University Medical Center & Duke Clinical Research Institute, Durham, NC, USA
| | - Diane M Francis
- Health Economics and Market Access, Johnson & Johnson Medical Devices, Irvine, CA, USA
| | - Sonia Maccioni
- Health Economics and Market Access, Johnson & Johnson Medical Devices, Irvine, CA, USA
| | | | - Paul Coplan
- Medical Device Epidemiology and Real-World Data Sciences, Johnson & Johnson, New Brunswick, NJ, USA
| | - Rahul Khanna
- Medical Device Epidemiology and Real-World Data Sciences, Johnson & Johnson, New Brunswick, NJ, USA
| | - Charlene Wong
- Medical Device Epidemiology and Real-World Data Sciences, Johnson & Johnson, New Brunswick, NJ, USA
| | - Neloufar Rahai
- Medical Device Epidemiology and Real-World Data Sciences, Johnson & Johnson, New Brunswick, NJ, USA
| | - Jonathan P Piccini
- Division of Cardiology, Duke University Medical Center & Duke Clinical Research Institute, Durham, NC, USA
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7
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Qeska D, Singh SM, Qiu F, Manoragavan R, Cheung CC, Ko DT, Sud M, Terricabras M, Wijeysundera HC. Variation and clinical consequences of wait-times for atrial fibrillation ablation: population level study in Ontario, Canada. Europace 2023; 25:euad074. [PMID: 36942997 PMCID: PMC10227764 DOI: 10.1093/europace/euad074] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 02/16/2023] [Indexed: 03/23/2023] Open
Abstract
AIMS Atrial fibrillation (AF) is the most common cardiac rhythm disorder. Emerging evidence supporting the efficacy of catheter ablation in managing AF has led to increased demand for this therapy, potentially outpacing the capacity to perform this procedure. Mismatch between demand and capacity for AF ablation results in wait-times which have not been comprehensively evaluated at a population level. Additionally, the consequences of such delays in AF ablation, namely the risk of hospitalization or adverse events, have not been studied. METHODS AND RESULTS This observational cohort study included adults referred for catheter ablation to treat AF in Ontario, Canada, between 1 April 2016 and 31 March 2020. Wait-time was defined from referral to the earliest of ablation, death, off-list, or the study endpoint of 31 March 2022. The outcomes of interest included a composite of death, hospitalization for AF/heart failure, and emergency department visit for AF/heart failure. Our study cohort included 6253 patients referred for de novo AF ablation. The median wait-time for patients who received and who did not receive ablation was 218 days (IQR: 112-363) and 520 days (IQR: 270-763), respectively. Wait-time increased consistently for patients referred between October 2017 and March 2020. Mortality was rare, but significant morbidity was observed, affecting 19.2% of patients on the waitlist for AF ablation. Paroxysmal AF was associated with a statistically significant greater risk for adverse outcomes on the waitlist (HR 1.51, 95% CI 1.18-1.93). CONCLUSION Wait-times for AF ablation are increasing and are associated with significant morbidity.
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Affiliation(s)
- Denis Qeska
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave., Room A202, Toronto, ON M4N 3M5, Canada
- Temerty Faculty of Medicine, University of Toronto, 1 King’s College Circle, Toronto, ON M5S 1A8, Canada
| | - Sheldon M Singh
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave., Room A202, Toronto, ON M4N 3M5, Canada
- Temerty Faculty of Medicine, University of Toronto, 1 King’s College Circle, Toronto, ON M5S 1A8, Canada
| | - Feng Qiu
- ICES, 2075 Bayview Ave., Room G1 06, Toronto, ON M4N 3M5, Canada
| | - Ragavie Manoragavan
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave., Room A202, Toronto, ON M4N 3M5, Canada
| | - Christopher C Cheung
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave., Room A202, Toronto, ON M4N 3M5, Canada
- Temerty Faculty of Medicine, University of Toronto, 1 King’s College Circle, Toronto, ON M5S 1A8, Canada
| | - Dennis T Ko
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave., Room A202, Toronto, ON M4N 3M5, Canada
- Temerty Faculty of Medicine, University of Toronto, 1 King’s College Circle, Toronto, ON M5S 1A8, Canada
- ICES, 2075 Bayview Ave., Room G1 06, Toronto, ON M4N 3M5, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College St., Toronto, ON M5T 3M6, Canada
| | - Maneesh Sud
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave., Room A202, Toronto, ON M4N 3M5, Canada
- Temerty Faculty of Medicine, University of Toronto, 1 King’s College Circle, Toronto, ON M5S 1A8, Canada
- ICES, 2075 Bayview Ave., Room G1 06, Toronto, ON M4N 3M5, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College St., Toronto, ON M5T 3M6, Canada
| | - Maria Terricabras
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave., Room A202, Toronto, ON M4N 3M5, Canada
- Temerty Faculty of Medicine, University of Toronto, 1 King’s College Circle, Toronto, ON M5S 1A8, Canada
| | - Harindra C Wijeysundera
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave., Room A202, Toronto, ON M4N 3M5, Canada
- Temerty Faculty of Medicine, University of Toronto, 1 King’s College Circle, Toronto, ON M5S 1A8, Canada
- ICES, 2075 Bayview Ave., Room G1 06, Toronto, ON M4N 3M5, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College St., Toronto, ON M5T 3M6, Canada
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8
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Hijazi W, Vandenberk B, Rennert-May E, Quinn A, Sumner G, Chew DS. Economic evaluation in cardiac electrophysiology: Determining the value of emerging technologies. Front Cardiovasc Med 2023; 10:1142429. [PMID: 37180811 PMCID: PMC10169721 DOI: 10.3389/fcvm.2023.1142429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 04/03/2023] [Indexed: 05/16/2023] Open
Abstract
Cardiac electrophysiology is a constantly evolving speciality that has benefited from technological innovation and refinements over the past several decades. Despite the potential of these technologies to reshape patient care, their upfront costs pose a challenge to health policymakers who are responsible for the assessment of the novel technology in the context of increasingly limited resources. In this context, it is critical for new therapies or technologies to demonstrate that the measured improvement in patients' outcomes for the cost of achieving that improvement is within conventional benchmarks for acceptable health care value. The field of Health Economics, specifically economic evaluation methods, facilitates this assessment of value in health care. In this review, we provide an overview of the basic principles of economic evaluation and provide historical applications within the field of cardiac electrophysiology. Specifically, the cost-effectiveness of catheter ablation for both atrial fibrillation (AF) and ventricular tachycardia, novel oral anticoagulants for stroke prevention in AF, left atrial appendage occlusion devices, implantable cardioverter defibrillators, and cardiac resynchronization therapy will be reviewed.
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Affiliation(s)
- Waseem Hijazi
- Libin Cardiovascular Institute, Department of Cardiac Sciences, University of Calgary, Calgary, AB, Canada
| | - Bert Vandenberk
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Elissa Rennert-May
- Libin Cardiovascular Institute, Department of Cardiac Sciences, University of Calgary, Calgary, AB, Canada
- O’Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Amity Quinn
- O’Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Glen Sumner
- Libin Cardiovascular Institute, Department of Cardiac Sciences, University of Calgary, Calgary, AB, Canada
| | - Derek S. Chew
- Libin Cardiovascular Institute, Department of Cardiac Sciences, University of Calgary, Calgary, AB, Canada
- O’Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
- Department of Medicine, University of Calgary, Calgary, AB, Canada
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9
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Reynolds MR. Addition by Subtraction: Disease Progression and the Value of Atrial Fibrillation Ablation. Circ Arrhythm Electrophysiol 2023; 16:e011918. [PMID: 37009736 PMCID: PMC10473022 DOI: 10.1161/circep.123.011918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2023]
Affiliation(s)
- Matthew R. Reynolds
- Division of Cardiology, Lahey Hospital & Medical Center, Burlington, MA. Baim Institute for Clinical Research, Boston, MA
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10
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Berman AE, Kabiri M, Wei T, Galvain T, Sha Q, Kuck KH. Economic and Health Value of Delaying Atrial Fibrillation Progression Using Radiofrequency Catheter Ablation. Circ Arrhythm Electrophysiol 2023; 16:e011237. [PMID: 36891899 PMCID: PMC10108841 DOI: 10.1161/circep.122.011237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 02/16/2023] [Indexed: 03/10/2023]
Abstract
BACKGROUND Radiofrequency catheter ablation (RFCA) is an established treatment for atrial fibrillation (AF) refractory to antiarrhythmic drugs. The economic value of RFCA in delaying disease progression has not been quantified. METHODS An individual-level, state-transition health economic model estimated the impact of delayed AF progression using RFCA versus antiarrhythmic drug treatment for a hypothetical sample of patients with paroxysmal AF. The model incorporated the lifetime risk of progression from paroxysmal AF to persistent AF, informed by data from the ATTEST (Atrial Fibrillation Progression Trial). The incremental effect of RFCA on disease progression was modeled over a 5-year duration. Annual crossover rates were also included for patients in the antiarrhythmic drug group to mirror clinical practice. Estimates of discounted costs and quality-adjusted life years asssociated with health care utilization, clinical outcomes, and complications were projected over patients' lifetimes. RESULTS From the payer's perspective, RFCA was superior to antiarrhythmic drug treatment with an estimated mean net monetary benefit per patient of $8516 ($148-$16 681), driven by reduced health care utilization, cost, and improved quality-adjusted life years. RFCA reduced mean (95% CI) per-patient costs by $73 (-$2700 to $2200), increased mean quality-adjusted life years by 0.084 (0.0-0.17) and decreased the mean number of cardiovascular-related health care encounters by 24%. CONCLUSIONS RFCA is a dominant (less costly and more effective) treatment strategy for patients with AF, especially those with early AF for whom RFCA could delay progression to advanced AF. Increased utilization of RFCA-particularly among patients earlier in their disease progression-may provide clinical and economic benefits.
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Affiliation(s)
- Adam E. Berman
- Divisions of Cardiology and Health Economics and Modeling, Departments of Medicine and Population Health Sciences, Medical College of Georgia, Augusta, GA (A.E.B.)
| | - Mina Kabiri
- Global Provider and Payer Value Demonstration, Global Health Economics, Johnson and Johnson Medical Devices, New Brunswick, NJ (M.K., T.G.)
| | - Tom Wei
- Biosense Webster, Inc, Franchise Health Economics (T.W.), Johnson and Johnson Medical Devices, Irvine, CA
| | - Thibaut Galvain
- Global Provider and Payer Value Demonstration, Global Health Economics, Johnson and Johnson Medical Devices, New Brunswick, NJ (M.K., T.G.)
| | - Qun Sha
- Biosense Webster, Inc, Medical Affairs (Q.S.), Johnson and Johnson Medical Devices, Irvine, CA
| | - Karl-Heinz Kuck
- Universitätsklinikum Schleswig-Holstein, Lübeck, Germany (K.-H.K.)
- LANS Cardio, Hamburg, Germany (K.-H.K.)
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11
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O'Byrne ML, Wilensky R, Glatz AC. Incorporating economic analysis in interventional cardiology research. Catheter Cardiovasc Interv 2023; 101:122-130. [PMID: 36480805 DOI: 10.1002/ccd.30506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 11/08/2022] [Accepted: 11/19/2022] [Indexed: 12/13/2022]
Abstract
Evaluative research in interventional cardiology has focused on clinical and technical outcomes. Inclusion of economic data can enhance evaluative research by quantifying the relative economic burden incurred by different therapies. When combined with clinical outcomes, cost data can provide a measure of value (e.g., marginal cost-effectiveness). In some select situations, cost data can also be used as surrogates for complexity of care and morbidity. In this narrative review, we aim to provide a framework for the application of cost data in clinical trials and observational research, detailing how to incorporate this kind of data into interventional cardiology research.
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Affiliation(s)
- Michael L O'Byrne
- Department of Pediatrics, Division of Cardiology and Clinical Futures, The Children's Hospital of Philadelphia, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute For Healthcare Economics, The University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Cardiovascular Outcomes, Quality, and Evaluative Research, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert Wilensky
- Center for Cardiovascular Outcomes, Quality, and Evaluative Research, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Internal Medicine, Division of Cardiology, The Hospital of The University of Pennsylvania, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrew C Glatz
- Department of Pediatrics, Division of Cardiology, Washington University School of Medicine, and St. Louis Children's Hospital, St. Louis, Missouri, USA
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12
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Healthcare Utilization and Outcomes in Atrial Fibrillation Patients Treated by Drug Therapy versus a Catheter Ablation Strategy-A Middle European Propensity Score Matched Cohort Study. J Cardiovasc Dev Dis 2022; 9:jcdd9120451. [PMID: 36547448 PMCID: PMC9781316 DOI: 10.3390/jcdd9120451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 11/28/2022] [Accepted: 12/05/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND AND AIMS Atrial fibrillation (AF) is the most prevalent arrhythmia, associated with increased mortality and morbidity and causing relevant costs. Treatment options consist of catheter ablation (PVI) and rate or rhythm control drugs (non-PVI). METHODS We analyze inpatient and outpatient data from the Upper Austrian Health Insurance Fund. Data of patients with a first hospitalization for AF in the years 2005 to 2018 were examined, using propensity score matching (PSM) including all CHA2DS2-VASc variables and working "collar". RESULTS Out of 21,791 AF patients, PSM identified 1013 well-matching pairs (PVI and non-PVI). Over a ten-year period, the PVI treatment strategy group reveals significantly higher inpatient and outpatient expenditures (€2200/year). Positive economic effects can be demonstrated by a 5.1 percentage points (pp) higher employment rate and fewer retirements (7.6pp). Of utmost important is the 5.8pp all-cause mortality reduction over 10 years in the PVI treatment strategy. CONCLUSIONS A PVI based treatment strategy results in higher healthcare expenditures vs. drug therapy alone. Most of these higher costs were caused by the PVI procedures during this period. Thus, more effective and efficient methods are needed to further reduce costs for the intervention and prevent repeat procedures. The benefit of a PVI treatment strategy is seen in higher employment rates, which are crucial from a societal perspective and should be a strong argument for caregivers. We show a significant reduction in all-cause mortality, which we partly attribute to the PVI procedure itself, to a stricter risk factor assessment and treatment, and a tighter medical adherence.
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13
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Osorio J, Mansour M, Melby D, Imhoff RJ, Hunter TD, Maccioni S, Wei T, Natale A. Economic Evaluation of Contact Force Catheter Ablation for Persistent Atrial Fibrillation in the United States. Heart Rhythm O2 2022; 3:647-655. [PMID: 36589917 PMCID: PMC9795304 DOI: 10.1016/j.hroo.2022.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Background Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia, and it increases the risk of stroke, heart failure, and other cardiac complications. Catheter ablation is well-established as a treatment for paroxysmal AF, and the recent PRECEPT (Prospective Review of the Safety and Effectiveness of the THERMOCOOL SMARTTOUCH SF Catheter Evaluated for Treating Symptomatic Persistent AF) clinical trial resulted in the catheter gaining approval for the treatment of persistent AF in the United States. Objectives To construct an economic simulation model, based on the results of the PRECEPT trial, to monetize the impact of radiofrequency catheter ablation (RFCA) compared with medical therapy (MT). Methods Cost-offset and break-even analyses were performed to assess the economic impact of RFCA vs MT for adult persistent AF patients. Three perspectives were considered: commercial payers, Medicare, and self-insured employers. A cohort-level decision tree model was developed and validated in TreeAge Pro 2019. Sensitivity analyses were performed to determine the robustness of findings. Results For all 3 types of payer, RFCA had a higher initial cost compared with MT. However, reductions in health care utilization after ablation, driven by decreased cardiovascular hospitalizations, led to an annual cost offset of between $5037 and $8402 after the first year. Projecting this forward resulted in an estimated cost break-even after 5.9, 4.2, and 5.1 years for commercial payers, Medicare, and self-insured employers, respectively. Conclusion In addition to providing clinical benefits, RFCA may be a valuable economic investment for U.S. payers, substantially reducing utilization after the first year.
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Affiliation(s)
- Jose Osorio
- Arrhythmia Institute at Grandview, Birmingham, Alabama
| | | | - Daniel Melby
- Minneapolis Heart Institute at Abbott-Northwestern Hospital, Minneapolis, Minnesota
| | - Ryan J. Imhoff
- Real-World Evidence, CTI Clinical Trial and Consulting Services, Covington, Kentucky
- Address reprint requests and correspondence: Mr Ryan J. Imhoff, Real World Evidence, CTI Clinical Trial & Consulting Services, 100 East Rivercenter Boulevard, Covington, KY 41011.
| | - Tina D. Hunter
- Real-World Evidence, CTI Clinical Trial and Consulting Services, Covington, Kentucky
| | - Sonia Maccioni
- Franchise Health Economics and Market Access, Johnson & Johnson, Irvine, California
| | - Tom Wei
- Franchise Health Economics and Market Access, Johnson & Johnson, Irvine, California
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute at St. David’s Medical Center, Austin, Texas
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14
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Duke JM, Muhammad LN, Song J, Tanaka Y, Witting C, Khan SS, Passman RS. Racial Disparity in Referral for Catheter Ablation for Atrial Fibrillation at a Single Integrated Health System. J Am Heart Assoc 2022; 11:e025831. [PMID: 36073632 DOI: 10.1161/jaha.122.025831] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Guidelines recommend catheter ablation of atrial fibrillation (AFCA) as an option for rhythm control. Studies have shown that Black patients are less likely to undergo AFCA compared with White patients. We investigated whether differences in referral patterns play a role in this observed disparity. Methods and Results Using an integrated repository from the electronic medical record at Northwestern Medicine, we conducted a retrospective cohort study of outpatients with newly diagnosed atrial fibrillation. Baseline characteristics by race and ethnicity were compared. Logistic regression models adjusted for socioeconomic and health factors were constructed to determine the association between race and ethnicity and binary dependent variables including referrals and visits to general cardiology and cardiac electrophysiology (EP) and AFCA. Of 5445 patients analyzed, 4652 were non-Hispanic White (NHW) and 793 were non-Hispanic Black (NHB). In adjusted models, NHB patients initially diagnosed with atrial fibrillation in internal medicine and primary care had a significantly greater odds of referral to general cardiology; among all patients in the cohort, there was no significant difference in the odds of referral to EP between NHB and NHW patients; and there were no differences in the odds of completing a visit in general cardiology or EP. Among patients completing an EP visit, NHB patients were less likely to undergo AFCA (odds ratio, 0.63 [95% CI, 0.40-0.98], P=0.040). Conclusions Similar referral rates to general cardiology and EP were observed between NHB and NHW patients. Despite this, NHB patients were less likely to undergo AFCA.
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Affiliation(s)
- Jessica M Duke
- Department of Medicine Northwestern University Feinberg School of Medicine Chicago IL
| | - Lutfiyya N Muhammad
- Department of Preventive Medicine Northwestern University Feinberg School of Medicine Chicago IL
| | - Jing Song
- Department of Preventive Medicine Northwestern University Feinberg School of Medicine Chicago IL
| | - Yoshihiro Tanaka
- Department of Preventive Medicine Northwestern University Feinberg School of Medicine Chicago IL.,Center for Arrhythmia Research Northwestern University Feinberg School of Medicine Chicago IL
| | - Celeste Witting
- Department of Medicine Northwestern University Feinberg School of Medicine Chicago IL
| | - Sadiya S Khan
- Department of Medicine Northwestern University Feinberg School of Medicine Chicago IL.,Department of Preventive Medicine Northwestern University Feinberg School of Medicine Chicago IL.,Department of Medicine, Division of Cardiology Northwestern University Feinberg School of Medicine Chicago IL
| | - Rod S Passman
- Department of Medicine Northwestern University Feinberg School of Medicine Chicago IL.,Department of Preventive Medicine Northwestern University Feinberg School of Medicine Chicago IL.,Center for Arrhythmia Research Northwestern University Feinberg School of Medicine Chicago IL.,Department of Medicine, Division of Cardiology Northwestern University Feinberg School of Medicine Chicago IL
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15
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Robinson A, Chopra N, Badin AG, Billakanty SR, Cooper K, Fu EY, James J, Murnane V, Swinning J, Stelzer M, Tyler JD, Amin AK. Impact of a dedicated atrial fibrillation clinic on diagnosis-to-ablation time. Heart Rhythm O2 2022; 3:639-646. [PMID: 36589916 PMCID: PMC9795309 DOI: 10.1016/j.hroo.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Background Outcomes following catheter ablation (CA) for atrial fibrillation (AF) improve as the diagnosis-to-ablation time (DAT) shortens. Use of a protocol-based integrated care model through a dedicated atrial fibrillation clinic (AFC) may serve to standardize treatment pathways and decrease DAT. Objective To evaluate the DAT and clinical characteristics of patients with AF referred from an AFC vs a conventional electrophysiology clinic (EC). Methods Retrospective analysis was completed in consecutive patients undergoing index AF ablation at Riverside Methodist Hospital in 2019 with minimum 1 year follow-up. Patients were categorized based off their CA referral source (AFC vs EC) and where the initial visit following index diagnosis of AF occurred (AFC vs EC). Results A total of 182 patients (mean age 65 years, 64% male) were reviewed. Patients referred from an AFC (21%) had a median DAT of 342 days (interquartile range [IQR], 125-855 days) compared to patients referred from EC (79%) with a median DAT of 813 days (IQR, 241-1444 days; P = .01). Patients with their index visit following AF diagnosis occurring in the AFC (9%) had significantly shorter median DAT (127 days [IQR, 95-188 days]) compared to EC (91%) (789 days [IQR, 253-1503 days]; P = .002). Patients with DAT <1 year had lower AF recurrence than patients with DAT >1 year (P = .04, hazard ratio = 0.58, 95% confidence interval 0.3418-1.000). Conclusion DAT is a modifiable factor that may affect CA outcomes. Significant reductions in DAT were observed in patients evaluated through a dedicated AF clinic.
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Affiliation(s)
- Andrea Robinson
- Section of Cardiac Electrophysiology, Department of Cardiology, OhioHealth Heart and Vascular Physicians, Riverside Methodist Hospital, Columbus, Ohio,Address reprint requests and correspondence: Ms Andrea Robinson, Section of Cardiac Electrophysiology, Department of Cardiology, OhioHealth Heart and Vascular Physicians, Riverside Methodist Hospital, 3535 Olentangy River Rd, Columbus, OH 43214.
| | - Nagesh Chopra
- Section of Cardiac Electrophysiology, Department of Cardiology, OhioHealth Heart and Vascular Physicians, Riverside Methodist Hospital, Columbus, Ohio
| | - Auroa G. Badin
- Section of Cardiac Electrophysiology, Department of Cardiology, OhioHealth Heart and Vascular Physicians, Riverside Methodist Hospital, Columbus, Ohio
| | - Sreedhar R. Billakanty
- Section of Cardiac Electrophysiology, Department of Cardiology, OhioHealth Heart and Vascular Physicians, Riverside Methodist Hospital, Columbus, Ohio
| | - Keaira Cooper
- Section of Cardiac Electrophysiology, Department of Cardiology, OhioHealth Heart and Vascular Physicians, Riverside Methodist Hospital, Columbus, Ohio
| | - Eugene Y. Fu
- Section of Cardiac Electrophysiology, Department of Cardiology, OhioHealth Heart and Vascular Physicians, Riverside Methodist Hospital, Columbus, Ohio
| | - Jennifer James
- Section of Cardiac Electrophysiology, Department of Cardiology, OhioHealth Heart and Vascular Physicians, Riverside Methodist Hospital, Columbus, Ohio
| | - Victoria Murnane
- Section of Cardiac Electrophysiology, Department of Cardiology, OhioHealth Heart and Vascular Physicians, Riverside Methodist Hospital, Columbus, Ohio
| | - Jill Swinning
- Section of Cardiac Electrophysiology, Department of Cardiology, OhioHealth Heart and Vascular Physicians, Riverside Methodist Hospital, Columbus, Ohio
| | - Mitchell Stelzer
- Department of Internal Medicine, OhioHealth Doctors Hospital, Columbus, Ohio
| | - Jaret D. Tyler
- Section of Cardiac Electrophysiology, Department of Cardiology, OhioHealth Heart and Vascular Physicians, Riverside Methodist Hospital, Columbus, Ohio
| | - Anish K. Amin
- Section of Cardiac Electrophysiology, Department of Cardiology, OhioHealth Heart and Vascular Physicians, Riverside Methodist Hospital, Columbus, Ohio
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16
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Doshi A, Maccioni S, Preethi SM, Khanna R. Catheter ablation using advanced porous tip contact force–sensing radiofrequency catheter: Impact on health care utilization among patients with persistent atrial fibrillation. Heart Rhythm O2 2022; 3:474-481. [PMID: 36340499 PMCID: PMC9626894 DOI: 10.1016/j.hroo.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 06/20/2022] [Accepted: 07/09/2022] [Indexed: 11/27/2022] Open
Abstract
Background Catheter ablation (CA) is an effective treatment for patients with persistent atrial fibrillation (PsAF); however, little is known about its impact on health care utilization for patients with PsAF. The ThermoCool SmartTouch SF (STSF) catheter (Biosense Webster) incorporates an advanced porous tip and contact force–sensing technology. Objective The purpose of this study was to determine health care utilization among patients with PsAF who underwent ablation with the STSF catheter. Methods A retrospective cohort study using the Premier Healthcare Database identified patients with PsAF undergoing CA with the STSF catheter in inpatient and outpatient settings. The proportion of patients experiencing AF-related inpatient admissions, outpatient admissions, emergency department (ED) visits, electrical cardioversion, and a composite outcome in the 12 months pre- vs postablation were compared using the McNemar test. Subanalyses were performed on study outcomes by race/ethnicity. Results The final sample included 3077 patients (mean age 65.9 years; 31.7% female). Among patients with PsAF undergoing ablation with the STSF catheter, relative reductions in health care utilization in the 12 months post- vs preablation included 55.3% in AF-related inpatient admissions (P <.0001), 38.9% in outpatient admissions (P <.0001), 52.4% in ED visits (P <.0001), and 61.2% in electrical cardioversions (P <.0001). Composite outcome utilization in the 12 months post- vs preablation declined by 40.2% (P <.0001) for the overall cohort, 40.0% for White patients (P <.0001), 52.2% for Black patients (P <.0001), and 50.1% for Asian patients (P = .032). Conclusion Significant improvements in health care utilization were observed among PsAF patients who underwent ablation using the STSF catheter. Improvements were particularly marked in underrepresented racial and ethnic groups.
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17
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Mohanty S, Natale A. Impact of Catheter Ablation on Quality of Life and Healthcare Utilisation. Arrhythm Electrophysiol Rev 2021; 10:258-261. [PMID: 35106178 PMCID: PMC8785075 DOI: 10.15420/aer.2021.50] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 10/14/2021] [Indexed: 11/13/2022] Open
Abstract
Impairment of quality of life (QoL) is a well-known complication of AF. Because of the association of AF with older age and many other cardiovascular comorbidities, there are multiple factors that could influence QoL score even after successful AF intervention. However, substantial improvement in QoL has been reported following catheter ablation for AF regardless of ablation outcomes. In terms of healthcare resource utilisation, the expenses associated with AF are very high because of the hospitalisations for AF-related thromboembolic complications, aggravation of heart failure, AF interventions, and emergency room visits for incessant arrhythmia episodes, and they represent a large economic burden worldwide. Several trials have shown a drastic reduction in healthcare costs following successful AF ablation. In this review, the authors discuss this evidence systematically.
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Affiliation(s)
- Sanghamitra Mohanty
- Texas Cardiac Arrhythmia Institute, St David’s Medical Center, Austin, TX, US
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St David’s Medical Center, Austin, TX, US
- Interventional Electrophysiology, Scripps Clinic, San Diego, CA, US
- Metro Health Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, US
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