Cost Comparison of Ablation Versus Antiarrhythmic Drugs As First-Line Therapy for Atrial Fibrillation: An Economic Evaluation of the RAAFT Pilot Study

Micro-Costing Analysis for the Treatment of Atrial Fibrillation: An Economic Evaluation of the First Italian Experience of Same-Day Discharge Protocol for Cryoballoon Atrial Fibrillation Ablation

Background: Atrial fibrillation (AF) is the most common cardiac arrhythmia, and its prevalence is expected to increase further due to the aging population, increasing prevalence of risk factors, improving detection methods, and broadening of catheter ablation indications. Along with limited healthcare resources and bed availability, these reasons led to the development of a same-day discharge (SDD) protocol. The aim of this study was to evaluate the health and economic impact of a routine adoption of same-day discharge after cryoballoon AF ablation. Methods: Consecutive patients with symptomatic and drug-refractory AF scheduled for first-time AF ablation were screened, and if deemed suitable, the SDD protocol was proposed and, if accepted, enrolled in the protocol. Results: A total of 324 patients were screened, and 118 were considered eligible for the SDD pathway. Fifty-two patients accepted the SDD pathway and were included in this study. The analysis showed that the variation in resource consumption associated with cryoablation in SDD is equal to EUR 739.85/patient. The analysis showed that the main cost driver for ordinary hospitalization was represented by the hospital stay, which was calculated to be 36% of the total cost. In total, there was a cost reduction of EUR 38.472 thanks to optimized AF patient management from the standard recovery setting to SDD. Conclusions: SDD after cryoballoon ablation of AF is feasible in selected patients with a standardized protocol.

The Cost-Effectiveness of First-Line Cryoablation vs First-Line Antiarrhythmic Drugs in Canadian Patients With Paroxysmal Atrial Fibrillation

BACKGROUND

The EARLY-AF (NCT02825979), STOP AF First (NCT03118518), and Cryo-FIRST (NCT01803438) randomised controlled trials (RCTs) demonstrated that cryoballoon pulmonary vein isolation reduces atrial fibrillation (AF) recurrence compared with antiarrhythmic drugs (AADs) in patients with symptomatic paroxysmal atrial fibrillation (PAF). The present study developed a cost-effectiveness model (CEM) of first-line cryoablation compared with first-line AADs for PAF, from the Canadian health care payer's perspective.

METHODS

Data from the 3 RCTs were analysed to estimate key CEM parameters. The model structure used a decision tree for the first 12 months and a Markov model with a 3-month cycle length for the remaining lifetime time horizon. Costs were set at 2023 Canadian dollars, health benefits were expressed as quality-adjusted life years (QALYs), and both were discounted 3% annually. Probabilistic sensitivity analysis (PSA) considered parameter uncertainty.

RESULTS

The statistical analysis estimated that first-line cryoablation generates a 47% reduction (P < 0.001) in the rate of AF recurrence, a 73% reduction in the rate of subsequent ablation (P < 0.001), and a 4.3% (P = 0.025) increase in health-related quality of life, compared with first-line AADs. The PSA indicates that an individual treated with first-line cryoablation accrues less costs (-$3,862) and more QALYs (0.19) compared with first-line AADs. Cryoablation is cost-saving in 98.4% of PSA iterations and has a 99.9% probability of being cost-effective at a cost-effectiveness threshold of $50,000 per QALY gained. Cost-effectiveness results were robust to changes in key model parameters.

CONCLUSIONS

First-line cryoballoon ablation is cost-effective when compared with AADs for patients with symptomatic PAF.

Catheter ablation versus medical therapy in atrial fibrillation: an umbrella review of meta-analyses of randomized clinical trials

This umbrella review synthesizes data from 17 meta-analyses investigating the comparative outcomes of catheter ablation (CA) and medical treatment (MT) for atrial fibrillation (AF). Outcomes assessed were mortality, risk of hospitalization, AF recurrence, cardiovascular events, pulmonary vein stenosis, major bleeding, and changes in left ventricular ejection fraction (LVEF) and MLHFQ score. The findings indicate that CA significantly reduces overall mortality and cardiovascular hospitalization with high strength of evidence. The risk of AF recurrence was notably lower with CA, with moderate strength of evidence. Two associations reported an increased risk of pulmonary vein stenosis and major bleeding with CA, supported by high strength of evidence. Improved LVEF and a positive change in MLHFQ were also associated with CA. Among patients with AF and heart failure, CA appears superior to MT for reducing mortality, improving LVEF, and reducing cardiovascular rehospitalizations. In nonspecific populations, CA reduced mortality and improved LVEF but had higher complication rates. Our findings suggest that CA might offer significant benefits in managing AF, particularly in patients with heart failure. However, the risk of complications, including pulmonary vein stenosis and major bleeding, is notable. Further research in understudied populations may help refine these conclusions.

Same-day discharge after atrial fibrillation ablation

Background

Atrial fibrillation (AF) catheter ablation has become an increasingly effective and safe strategy for the management of AF. With increased safety of catheter ablation, same-day discharge (SDD) is a potential way to minimize health care resource utilization and improve patient experience.

Objective

To evaluate the safety and patient satisfaction of SDD after contemporary AF ablation.

Methods

Consecutive patient undergoing AF ablation at our institution between 1/2020 and 10/2021 were enrolled in registry for clinical, quality, procedural and outcomes data. Patients were considered for SDD per physician discretion and patients' preference based upon clinical evaluation. Adjudicated ninety-day major complications, thirty-day adverse events, and thirty-day re-admissions were collected in a prospective registry for all patients.

Results

A total of 2142 consecutive patients underwent elective AF ablation during the study period. After excluding cases with missing data, 1830 patients were included in the analysis. Of those, 350 (19 %) patients were discharged the same day (SDD group) and 1480 (81 %) stayed overnight. Patients in the SDD group compared to overnight stay group were younger, more likely to be male, White patients, lower CHA2DS2-VASc score and to be on lower rates of warfarin as an anticoagulation strategy. After propensity score matching, SDD was associated with lower rate of major complications and higher patient satisfaction. The majority of life-treating complications occurred interprocedurally or within 6 h of procedure termination.

Conclusion

The present study demonstrated that SDD after contemporary AF ablation is feasible, safe and associated with higher patient satisfaction using a proposed SDD pathway and criteria.

Economic Evaluation of Catheter Ablation Versus Medical Therapy for the Treatment of Atrial Fibrillation from the Perspective of the UK

Randomised evidence supports an early rhythm control strategy as treatment for AF, and catheter ablation outperforms medical therapy in terms of effectiveness when studied as first- and second-line treatment. Despite evidence consistently showing that catheter ablation treatment is superior to medical therapy in most AF patients, only a small proportion receive ablation, in some cases after a prolonged trial of ineffective medical therapy. Health economics research in electrophysiology remains limited but is recognised as being important in influencing positive change to ensure early access to ablation services for all eligible patients. Such information has informed the updated recommendations from the recently published National Institute for Health and Care Excellence clinical guideline on the diagnosis and management of AF, but increased awareness is needed to drive real-world adoption and to ensure patients are quickly referred to specialists. In this article, economic evaluations of catheter ablation versus medical therapy are reviewed.

Long-Term Cost-Effectiveness Comparison of Catheter Ablation and Antiarrhythmic Drugs in Atrial Fibrillation Treatment Using Discrete Event Simulation

OBJECTIVES

To evaluate the lifetime cost-effectiveness of 3 widely used atrial fibrillation (AF) treatments from the perspectives of Chinese healthcare system: antiarrhythmic drugs (AADs), ThermoCool SmartTouch guided by ablation index (STAI), and second-generation cryoballoon (CB2).

METHODS

A discrete event simulation (DES) model was implemented to compare the lifetime cost-effectiveness of AADs, STAI, and CB2. AF disease progression was explicitly modeled based on the Atrial Fibrillation Progression Trial clinical study results. The base-case analysis assumed that patients with paroxysmal AF (PAF) entered the model at the age of 55 years and had a CHA2DS2-VASc (Congestive heart failure, Hypertension, Age ( > 65 = 1 point, > 75 = 2 points), Diabetes, previous Stroke/transient ischemic attack (2 points)-Vascular disease (peripheral arterial disease, previous myocardial infarction, aortic atheroma), Age 65 to 74 years, and Sex category) score of 2 for males and 3 for females. Model parameter uncertainties were incorporated throughout the DES simulation with full probabilistic model parameterization.

RESULTS

The lifetime cost-effectiveness evaluations showed that patients treated with AADs gained an average of 4.98 quality-adjusted life-years (QALYs) and 9.63 life-years (LYs) at an average cost of US dollar (USD) 15 374. Patients treated with CB2 gained 5.92 QALYs and 10.74 LYs at an average cost of USD 26 811. The STAI group gained an average of 6.55 QALYs and 11.57 LYs at an average cost of USD 24 722. The incremental cost-effectiveness ratios was USD 5927 and USD 12 167 per QALY for STAI versus AADs and CB2 versus AADs, respectively. Assuming the willingness-to-pay threshold for China is USD 30 390 per QALY, both ablation treatments will be cost-effective compared with AADs for patients with PAF.

CONCLUSIONS

The DES model demonstrated that catheter ablations are more cost-effective than AADs for patients with PAF under the healthcare system in China. Among catheter ablation technologies, STAI provides better outcomes at lower costs.

Long-Term Outcomes and Improvements in Quality of Life in Patients with Atrial Fibrillation Treated with Catheter Ablation vs. Antiarrhythmic Drugs

BACKGROUND

Catheter ablation (CA) is a recognized first-line treatment for atrial fibrillation (AF) in selected patients; however, the differences between CA and antiarrhythmic drugs (AADs) in terms of long-term outcomes and quality of life (QoL) have not often been compared.

OBJECTIVES

We performed a meta-analysis of randomized controlled trials (RCTs) to compare long-term outcomes and QoL with CA and AADs in the treatment of AF.

METHODS

We searched the MEDLINE database for English-language RCTs of CA or AADs in AF from 1 January 2005 to 30 October 2019 with no other restrictions. We included studies that reported sample sizes and the long-term outcomes of interest as well as sample size, mean ± standard deviation or 95% confidence intervals (CIs) for QoL outcomes with CA and AADs.

RESULTS

We identified 20 RCTs involving 5425 participants. Compared with patients who received only AADs, patients receiving CA had a significantly decreased risk of all-cause death (relative risk [RR] 0.72; 95% CI 0.58-0.90) and cardiovascular hospitalization (RR 0.85; 95% CI 0.79-0.91). We found a significant increase in the risk of cardiac tamponade (RR 5.86; 95% CI 1.77-19.44) but no difference in the risk of heart failure, stroke or transient ischemic attack, atrial tachycardia, bleeding or hematoma, and pulmonary vein stenosis. For long-term QoL after treatment, both therapies resulted in improved scores on the Medical Outcomes Study 36-Item Short Form Survey (SF-36): weighted mean differences (WMDs) for the physical component score (PCS) were 5.89 for CA and 4.26 for AADs and for the mental component score (MCS) were 7.12 for CA and 5.06 for AADs. At the end of follow-up, groups receiving CA had significantly higher scores in both areas. The change in PCS and MCS between baseline and end of follow-up was also significantly higher in the CA groups: WMD 1.51 for change in PCS and 1.49 for change in MCS. All eight SF-36 subscale scores improved for patients receiving CA, whereas patients receiving AADs recorded no improvement in the general health and bodily pain subscales. At the end of follow-up, CA groups had significantly higher scores than AAD groups in the following subscales: physical functioning, role limitations due to physical health problems, bodily pain, general health, vitality, and role limitations due to emotional problems.

CONCLUSIONS

In the treatment of AF, CA appeared to be superior to AADs, decreasing the risk of all-cause death and cardiovascular hospitalization and improving the long-term QoL of patients with AF. CA was better tolerated and more effective than pharmacological therapy and allowed for improved QoL.

A Long-Term Cost-Effectiveness Analysis Comparing Radiofrequency Catheter Ablation with Antiarrhythmic Drugs in Treatment of Chinese Patients with Atrial Fibrillation

INTRODUCTION

Radiofrequency catheter ablation (RFCA) is widely used to treat atrial fibrillation (AF) in China.

OBJECTIVE

We aimed to determine the long-term cost effectiveness of RFCA versus antiarrhythmic drugs (AADs) in treating AF from the perspective of third-party payers.

METHODS

The model was structured as a 12-month decision tree leading to a Markov model that simulated the follow-up treatment outcomes and costs with time horizons of 8, 15, and 20 years. Comparators were standard-of-care AADs. Clinical parameters captured normal sinus rhythm, AF, stroke, post-stroke, intracranial hemorrhage (ICH), gastrointestinal bleeding, post-ICH, and death. The risk of operative death, procedural complications, and adverse drug toxicity were also considered. The model output was quality-adjusted life-years (QALYs) and incremental cost per QALY gained.

RESULTS

RFCA incurred more costs than the AADs but resulted in more QALYs gained than did AADs. The incremental cost per QALY gained with RFCA versus AADs was ¥66,764, ¥36,280, and ¥29,359 at 8, 15, and 20 years, respectively. The sensitivity analyses showed that the results were most sensitive to the changes in RFCA cost and CHADS₂ score (clinical prediction rule for assessing the risk of stroke in patients with non-rheumatic AF).

CONCLUSION

Compared with AADs, RFCA significantly improves clinical outcomes and QALYs among patients with paroxysmal or persistent AF. From the Chinese payer's perspective, RFCA is a cost-effective therapy over long-term horizons.

Healthcare Utilization and Costs Reduction after Radiofrequency Ablation For Atrial Fibrillation in the Brazilian Private Healthcare System

Background

Atrial fibrillation (AF) is the most common arrhythmia worldwide, with significantly associated hospitalizations. Considering its growing incidence, the AF related economic burden to healthcare systems is increasing. Healthcare expenditures might be substantially reduced after AF radiofrequency ablation (AFRA).

Objective

To compare resource utilization and costs before and after AFRA in a cohort of patients from the Brazilian private healthcare system.

Methods

We conducted a retrospective cohort study, based on patients’ billing information from an administrative database. Eighty-three adult patients who had an AFRA procedure between 2014 and 2015 were included. Healthcare resource utilization related to cardiovascular causes, including ambulatory and hospital care, as well as its costs, were analyzed. A p-value of less than 0.05 was considered statistically significant.

Results

Mean follow-up was 14.7 ± 7.1 and 10.7 ± 5.4 months before and after AFRA, respectively. The 1-year AF recurrence-free rate was 83.6%. Before AFRA, median monthly total costs were Brazilian Reais (BRL) 286 (interquartile range [IQR]: 137-766), which decreased by 63.5% (p = 0.001) after the procedure, to BRL 104 (IQR: 57-232). Costs were reduced both in the emergency (by 58.6%, p < 0.001) and outpatient settings (by 56%, p < 0.001); there were no significant differences in the outpatient visits, inpatient elective admissions and elective admission costs before and after AFRA. The monthly median emergency department visits were reduced (p < 0.001).

Conclusion

In this cohort, overall healthcare costs were reduced by 63.5%. A longer follow-up could be useful to evaluate if long-term cost reduction is maintained.

Real-world outcomes, complications, and cost of catheter-based ablation for atrial fibrillation: an update

PURPOSE OF REVIEW

Catheter-based ablation for atrial fibrillation is a useful and effective form of rhythm-control therapy for symptomatic patients. This article reviews the 'real-world' experience on the outcomes, complications, and costs of atrial fibrillation ablation.

RECENT FINDINGS

Currently, real-world outcomes of atrial fibrillation ablation are derived from retrospective analysis of administrative databases or prospective registries from selected centers and patients. The rate of atrial fibrillation recurrence was reported to be as high as 60% and the rate of repeat ablation ranged from ≈10 to 18% within 1 year after ablation. All-cause hospitalizations after atrial fibrillation ablation were frequent, at up to ≈30% within 1 year and with up to half of them related to atrial fibrillation recurrence or repeat procedures. Rates of periprocedural complications were relatively low (≈3%). Female sex was associated with higher risk of complications such as bleeding, vascular injury, and tamponade. Markov models examining the cost-effectiveness of ablation yielded favorable results when success rates of more than 70% were assumed with long time horizons (>5 years).

SUMMARY

The real-world outcomes of atrial fibrillation ablation are sobering. Confirmation of these findings with prospective, population-based, minimally biased studies is needed. There is a critical need to delineate the downstream economic impact of atrial fibrillation ablation on society to justify its continued delivery and growth.

Cost-Effectiveness and Clinical Effectiveness of the Risk Factor Management Clinic in Atrial Fibrillation: The CENT Study

BACKGROUND

Atrial fibrillation (AF) imposes a substantial cost burden on the healthcare system. Weight and risk factor management (RFM) reduces AF burden and improves the outcomes of AF ablation.

OBJECTIVES

This study sought to evaluate the cost and clinical effectiveness of integrating RFM into the overall management of AF.

METHODS

Of 1,415 consecutive patients with symptomatic AF, 825 patients had body mass index ≥27 kg/m². After screening for exclusion criteria, the final cohort comprised 355 patients: 208 patients who opted for RFM and 147 control subjects and were followed by 3 to 6 monthly clinic review, 7-day Holter monitoring, and AF Symptom Score. A decision analytical model calculated the incremental cost-effectiveness ratios of cost per unit of global well-being gained and unit of AF burden reduced.

RESULTS

There were no differences in baseline characteristics or follow-up duration (p = NS). Arrhythmia-free survival was better in the RFM compared with control subjects (Kaplan-Meier: 79% vs. 44%; p < 0.001). At follow-up, RFM group had less unplanned specialist visits (0.19 ± 0.40 vs. 1.94 ± 2.00; p < 0.001), hospitalizations (0.74 ± 1.3 vs. 1.05 ± 1.60; p = 0.03), cardioversions (0.89 ± 1.50 vs. 1.51 ± 2.30; p = 0.002), emergency presentations (0.18 ± 0.50 vs. 0.76 ± 1.20; p < 0.001), and ablation procedures (0.60 ± 0.69 vs. 0.72 ± 0.86; p = 0.03). Antihypertensive (0.53 ± 0.70 vs. 0.78 ± 0.60; p = 0.04) and antiarrhythmic (0.26 ± 0.50 vs. 0.91 ± 0.60; p = 0.003) use declined in RFM. The RFM group had an increase of 0.1930 quality-adjusted life years and a cost saving of $12,094 (incremental cost-effectiveness ratios of $62,653 saved per quality-adjusted life years gained).

CONCLUSIONS

A structured physician-directed RFM program is clinically effective and cost saving.

Ablation as First-Line Therapy for Atrial Fibrillation: Yes

This article addresses the use of catheter ablation (CA) as first-line therapy for atrial fibrillation (AF). CA increases long-term freedom from AF, reduces hospitalizations, and improves quality of life compared with antiarrhythmic drug (AAD) therapy in patients with symptomatic AF who have already failed one AAD. The role of CA as first-line therapy for AF, however, is still controversial. Evidence from randomized controlled trials shows that CA is definitely superior to AADs as first-line therapy for relatively young patients with paroxysmal AF, with comparable complication rates and results consistently reproducible across different institutions, operators, and types of ablation approaches.

Ablation of atrial fibrillation

Ablation is increasingly used to treat AF, since recent trials of pharmacological therapy for AF have been disappointing. Ablation has been shown to improve maintenance of sinus rhythm compared to pharmacological therapy in many multicenter trials, although success rates remain suboptimal. This review will discuss several trends in the field of catheter ablation, including studies to advance our understanding of AF mechanisms in different patient populations, innovations in detecting and classifying AF, use of this information to improve strategies for ablation, technical innovations that have improved the ease and safety of ablation, and novel approaches to surgical therapy and imaging. These trends are likely to further improve results from AF ablation in coming years as it becomes an increasingly important therapeutic option for many patients.

Effect of catheter ablation versus antiarrhythmic drugs on atrial fibrillation: A meta-analysis of randomized controlled trials

The aim of the present study was to compare the health outcomes of catheter ablation therapy against those of antiarrhythmic drugs (AADs) in the management of atrial fibrillation (AF). The effects of catheter ablation and AADs on a number of parameters were compared, including AF recurrence, all-cause mortality, stroke/transient ischemic attack (TIA) and quality of life (QoL). A systematic literature search of PubMed, Embase and the Cochrane Central Register of Controlled Trials was conducted to obtain relevant randomized controlled trials. The relative risks (RRs) and 95% confidence intervals (CIs) of AF recurrence, all-cause mortality and stroke/TIA between catheter ablation and AADs were subsequently calculated. Weighted mean differences (WMDs) and 95% CIs were used to evaluate the QoL between the two therapy groups. In total, 11 randomized trials, which included 1,763 AF patients, were eligible for the meta-analysis. Overall, the results indicated that catheter ablation produces superior outcomes compared with AADs in reducing AF recurrence (RR, 0.47; 95% CI, 0.38-0.58; P<0.001) and improving the QoL (physical component summary: WMD, 2.23; 95% CI, 0.24-4.21; P=0.03; mental component summary: WMD, 2.69; 95% CI, 0.04-5.35; P=0.05). However, no statistically significant difference was identified between the two groups with regard to the incidence of all-cause mortality (RR, 0.87; 95% CI, 0.37-2.06; P=0.76) and stroke/TIA (RR, 1.83; 95% CI, 0.73-4.55; P=0.20). In summary, catheter ablation was demonstrated to markedly reduce AF recurrence and improve QoL when compared with AAD therapy. However, the incidence rates of all-cause mortality and stroke/TIA were comparable between catheter ablation and AAD therapy.

New Mechanism-based Approaches to Ablating Persistent AF: Will Drug Therapy Soon Be Obsolete?

Persistent atrial fibrillation (AF) represents a major public health and medical challenge. The progressive nature of the disease, high morbidity, and increasing health-economic costs ensure that it remains at the forefront of novel research into mechanisms and potential therapies. These are largely divided into pharmacological (drugs) and electrical (ablation) with patients often going from former to latter. AF ablation has improved sufficiently to be offered as first line for paroxysmal AF, but whether drug therapy will or be relegated. In this review, we shall outline the progress in mechanistic understanding of AF that may allow results from ablation to diverge dramatically from drug therapy and identify populations in whom drug therapy may become less relevant. We end by looking ahead to future developments that we hope will spur on therapeutic efficacy in both fields.

Variability of P-wave morphology predicts the outcome of circumferential pulmonary vein isolation in patients with recurrent atrial fibrillation

INTRODUCTION

Severe atrial structural remodeling may reflect irreversible damage of the atrial tissue in patients with atrial fibrillation (AF) and is associated with changes of P-wave duration and morphology. Our aim was to study whether variability of P-wave morphology (PMV) is associated with outcome in patients with AF after circumferential PV isolation (CPVI).

METHODS AND RESULTS

70 consecutive patients (aged 60±9years, 46 men) undergoing CPVI due to symptomatic AF were studied. After cessation of antiarrhythmic therapy, standard 12-lead ECG during sinus rhythm was recorded for 10min at baseline and transformed to orthogonal leads. Beat-to-beat P-wave morphology was subsequently defined using a pre-defined classification algorithm. The most commonly observed P-wave morphology in a patient was defined as the dominant morphology. PMV was defined as the percentage of P waves with non-dominant morphology in the 10-min sample. At the end of follow-up, 53 of 70 patients had no arrhythmia recurrence. PMV was greater in patients without recurrence (19.5±17.1% vs. 8.2±6.7%, p<0.001). In the multivariate logistic regression model, PMV≥20% (upper tertile) was the only independent predictor of ablation success (OR=11.4, 95% CI 1.4-92.1, p=0.023). A PMV≥20% demonstrated a sensitivity of 41.5%, a specificity of 94.1%, a PPV of 96.7%, and an NPV of 34.0% for free of AF after CPVI.

CONCLUSIONS

We report a significant association between increased PMV and 6-month CPVI success. PMV may help to identify patients with very high likelihood of freedom of AF 6-months after CPVI.

The cost-effectiveness of radiofrequency catheter ablation as first-line treatment for paroxysmal atrial fibrillation: results from a MANTRA-PAF substudy

AIM

The aim of this prospective substudy was to estimate the cost-effectiveness of treating paroxysmal atrial fibrillation (AF) with radiofrequency catheter ablation (RFA) compared with antiarrhythmic drugs (AADs) as first-line treatment.

METHODS AND RESULTS

A decision-analytic Markov model, based on MANTRA-PAF (Medical Antiarrhythmic Treatment or Radiofrequency Ablation in Paroxysmal Atrial Fibrillation) study data, was developed to study long-term effects and costs of RFA compared with AADs as first-line treatment. Positive clinical effects were found in the overall population, a gain of an average 0.06 quality-adjusted life years (QALYs) to an incremental cost of €3033, resulting in an incremental cost-effectiveness ratio of €50 570/QALY. However, the result of the subgroup analyses showed that RFA was less costly and more effective in younger patients. This implied an incremental cost-effectiveness ratio of €3434/QALY in ≤50-year-old patients respectively €108 937/QALY in >50-year-old patients.

CONCLUSION

Radiofrequency catheter ablation as first-line treatment is a cost-effective strategy for younger patients with paroxysmal AF. However, the cost-effectiveness of using RFA as first-line therapy in older patients is uncertain, and in most of these AADs should be attempted before RFA (MANTRA-PAF ClinicalTrials.gov number; NCT00133211).

Catheter ablation of atrial fibrillation: an update

Catheter ablation of atrial fibrillation (AF) is now an important therapeutic modality for patients with AF. There is considerable evidence available from several prospective randomized trials demonstrating that catheter ablation of AF is superior to antiarrhythmic drug therapy in controlling AF and that AF ablation improves quality of life substantially. This is especially true for patients with paroxysmal AF without other severe comorbidities. Catheter ablation is indicated for treatment of patients with symptomatic AF in whom one or more attempts at class 1 or 3 antiarrhythmic drug therapy have failed. Although current guidelines state that is appropriate to perform catheter ablation as a first-line therapy in selected patients, in our clinical practice this is rare. This reflects a number of important realities concerning the field of AF ablation. Catheter ablation of AF is a challenging and complex procedure, which is not free of the risk of potentially life-threatening complications, such as an atrio-oesophageal fistula, stroke, and cardiac tamponade. Although these major complications are rare and their rate is falling, they must be considered by both patients and physicians. The progress made and the new developments on the horizon in the field of AF catheter ablation are remarkable. When radiofrequency catheter ablation was first introduced in the late 1980s, few would have predicted that catheter ablation of AF would emerge as the most commonly performed ablation procedure in most major hospitals.

Optimal rhythm-control strategy for recurrent atrial tachycardia after catheter ablation of persistent atrial fibrillation: a randomized clinical trial

AIM

Although catheter ablation (CA) has replaced antiarrhythmic drugs (AAD) as first-line treatment in selected patients with atrial fibrillation (AF), optimal treatment of recurrent atrial tachycardia (AT) after AF ablation remains unclear. This parallel randomized controlled study compared CA vs. AAD for recurrent AT after persistent AF ablation.

METHODS AND RESULTS

Two-hundred and one patients (aged 59.1 ± 10.9 years, 68.7% male) with recurrent AT after persistent AF ablation were enrolled and randomized to either CA (n = 101) or AAD (n = 100) treatment. Primary endpoint was freedom from recurrent atrial tachyarrhythmia (ATa, including AT and AF) at 24-month follow-up. Composite secondary endpoints comprised procedural complications, long-term morbidity and improvement in quality of life (QoL). On an intention-to-treat basis, the CA group had a higher rate of freedom from recurrent ATa (56.4 vs. 34.0%; P = 0.001). Adjusted Cox regression analysis showed a significant treatment effect with a hazard ratio of 0.538 (95% CI: 0.355-0.816) in favour of CA. There was a higher proportion of periprocedural complications in the CA group (7.9 vs. 0; P = 0.012), and of long-term adverse events in the AAD group (10.9 vs. 24.0%; P = 0.014). Quality of life was significantly higher for CA.

CONCLUSIONS

This study demonstrates superiority of CA over AAD for recurrent AT after persistent AF ablation with regard to SR maintenance, long-term safety and QoL improvement. However, CA use might be limited by a higher risk for periprocedural complications.

Cost-Effectiveness of Atrial Fibrillation Ablation

Atrial fibrillation (AF) is a frequently encountered rhythm disorder, characterized by high recurrence rate, frequent hospitalizations, reduced quality-of-life and increased the risk of mortality, heart failure and stroke. Along with these clinical complications this type of arrhythmia is the major driver of health-related expenditures. Radiofrequency catheter ablation (RFA) of atrial fibrillation has been shown to improve freedom from arrhythmia survival, reduce re-hospitalization rate and provide better quality-of-life as compared with rate control and rhythm control with antiarrhythmic therapy. Efficacy of AF ablation in terms of outcomes and costs has an evolving importance. In this review, we aimed to highlight current knowledge on AF ablation clinical outcomes based on results of randomized clinical trials and community-based studies, and overview how this improvement in clinical end-points affects costs for arrhythmia care and cost-effectiveness of AF ablation.

Comparing Antiarrhythmic Drugs and Catheter Ablation for Treatment of Atrial Fibrillation

In the past years, catheter ablation has evolved into an effective treatment option for symptomatic, drug-resistant atrial fibrillation (AF) and it has recently been implemented as a primary treatment strategy for patients with paroxysmal AF. Although a significant number of studies have evaluated the potential benefits of catheter ablation compared with anti-arrhythmic drug (AAD)-therapy, to date, there are only a small number of randomised controlled trials in the literature, and several issues remain unsolved. The aim of this review is to analyze the current literature regarding this important issue and further discuss the question, whether catheter ablation may be more beneficial when compared to AAD therapy.

Cost effectiveness of antiarrhythmic medications in patients suffering from atrial fibrillation

Atrial fibrillation (AF), a supraventricular tachycardia disorder, is the most common sustained cardiac arrhythmia affecting 1-2 % of the general population. Prevalence is highly related to age, with every fourth individual older than 40 years old developing AF during his lifetime. Due to an aging population, the prevalence of AF is estimated to at least double within the next 50 years. This article presents AF-related cost-of-illness studies and reviews 19 cost-effectiveness studies and six cost studies published roughly over the past decade, which have compared different antiarrhythmic medications for AF. A systematic literature search for studies published between June 2000 and December 2011 was conducted in PubMed using the combination of keywords ((atrial fibrillation OR atrial flutter) AND cost). Current cost-effectiveness analyses of dronedarone and the pill-in-the-pocket strategy are subject to substantial uncertainties with regard to clinical benefit. Comparing rate control with rhythm control, a cost-effectiveness advantage for rate control was shown in several but not all studies. Within antiarrhythmic drug treatments, magnesium added onto ibutilide was shown to be more cost effective than ibutilide alone. Comparing chemical and electrical cardioversion, the latter was recommended as more cost effective from the healthcare system perspective in all reviewed studies but one. Catheter ablation appeared more cost effective than antiarrhythmic drugs in the medium to long run after 3.2-63.9 years. Admissions to hospital, inpatient care and interventional procedures as well as mortality benefit are key drivers for the cost effectiveness of AF medications. No clear cost-effectiveness advantage emerged for one specific antiarrhythmic drug from the studies that compared antiarrhythmic agents. Rate control as well as catheter ablation appear more cost effective than rhythm control in the treatment of AF. Rate control treatment also seems more cost effective than electrical cardioversion in AF patients.

Cost-benefit and cost-savings analyses of antiarrhythmic medication monitoring

PURPOSE

The economic impact of pharmacist-managed antiarrhythmic drug therapy monitoring on an academic medical center's electrophysiology (EP) program was investigated.

METHODS

Data were collected for the initial two years of patient visits (n = 816) to a pharmacist-run clinic for antiarrhythmic drug therapy monitoring. A retrospective cost analysis was conducted to assess the direct costs associated with three appointment models: (1) a clinic office visit only, (2) a clinic visit involving electrocardiography and basic laboratory tests, and (3) a clinic visit including pulmonary function testing and chest x-rays in addition to electrocardiography and laboratory testing. A subset of patient cases (n = 18) were included in a crossover analysis comparing pharmacist clinic care and usual care in an EP physician clinic. The primary endpoints were the cost benefits and cost savings associated with pharmacy-clinic care versus usual care. A secondary endpoint was improvement of overall EP program efficiency.

RESULTS

The payer mix was 61.6% (n = 498) Medicare, 33.2% (n = 268) managed care, and 5.2% (n = 42) other. Positive contribution margins were demonstrated for all appointment models. The pharmacist-managed clinic also yielded cost savings by reducing overall patient care charges by 21% relative to usual care. By the second year, the pharmacy clinic improved EP program efficiency by scheduling an average of 24 patients per week, in effect freeing up one day per week of EP physician time to spend on other clinical activities.

CONCLUSION

Pharmacist monitoring of antiarrhythmic drug therapy in an out-patient clinic provided cost benefits, cost savings, and improved overall EP program efficiency.

Cost of atrial fibrillation: invasive vs non-invasive management in 2012

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia. It places an enormous burden on the patients, caregivers and the society at large. As a chronic illness, AF accrues significant costs related to clinical presentation, complications and loss of productivity. Novel invasive approaches to AF promise a cure in some patients and a significant reduction in AF burden in others, but are very expensive. This paper will address the cost of conventional and invasive strategies in AF care and will review the evidence on the comparative cost effectiveness of these approaches.

A review of the cost of atrial fibrillation

OBJECTIVES

To systematically review and synthesize the literature on the costs of atrial fibrillation (AF) with attention to study design and costing methods, geography, and intervention approaches.

METHODS

A systematic search for previously published studies reporting the costs for AF patients was conducted. Data were analyzed in three steps: first by evaluating overall system costs; second by evaluating the relative contribution of specific cost components; and third by examining variations across study designs, across primary treatment approach, and by geography. Finally, a specific review of the treatment costs associated with anticoagulation treatment was examined given the clinical importance and attention given to these costs in the literature.

RESULTS

The literature search resulted in 115 articles. On review of the abstracts or full text of these articles, 21 articles met all study criteria and reported on health system AF-related direct costs. A further six articles focused exclusively on anticoagulation costs for patients with AF. The overall average annual system cost across 27 estimates obtained from the literature was $5450 (SD = $3624) in 2010 Canadian dollars and ranged from a low of $1,632 to a high of $21,099. About one-third of these costs could be attributed to anticoagulation management. The largest cost component was acute care, followed by outpatient and physician and then medication-related costs.

CONCLUSION

AF-related medical costs are high, reflecting resource-intensive and long-term treatments including anticoagulation treatment. These costs, accompanied with increasing prevalence, justify increased attention to the management of patients with AF. Future studies of AF cost should ensure a broad assessment of the incremental direct medical and societal cost associated with this diagnosis.

Rationale and current perspective for early rhythm control therapy in atrial fibrillation

Atrial fibrillation (AF) is the most common sustained arrhythmia and an important source for mortality and morbidity on a population level. Despite the clear association between AF and death, stroke, and other cardiovascular events, there is no evidence that rhythm control treatment improves outcome in AF patients. The poor outcome of rhythm control relates to the severity of the atrial substrate for AF not only due to the underlying atrial remodelling process but also due to the poor efficacy and adverse events of the currently available ion-channel antiarrhythmic drugs and ablation techniques. Data suggest, however, an association between sinus rhythm maintenance and improved survival. Hypothetically, sinus rhythm may also lead to a lower risk of stroke and heart failure. The presence of AF, thus, seems one of the modifiable factors associated with death and cardiovascular morbidity in AF patients. Patients with a short history of AF and the underlying heart disease have not been studied before. It is fair to assume that abolishment of AF in these patients is more successful and possibly also safer, which could translate into a prognostic benefit of early rhythm control therapy. Several trials are now investigating whether aggressive early rhythm control therapy can reduce cardiovascular morbidity and mortality and increase maintenance of sinus rhythm. In the present paper we describe the background of these studies and provide some information on their design.

Catheter ablation of atrial fibrillation as first-line therapy--a single-centre experience

AIMS

The aims of the study were (i) to assess the characteristics of patients selected for atrial fibrillation (AF) ablation as first-line therapy, (ii) to identify current clinical criteria for such a strategy, and (iii) to analyse the outcome compared with patients who had failure of antiarrhythmic drug (AAD) therapy prior to ablation.

METHODS AND RESULTS

Consecutive patients undergoing ablation of AF were included in a prospective registry. Serial long-term electrocardiogram monitoring and clinical follow-up were performed after 3, 6, and 12 months. Out of 434 patients, 17% underwent AF catheter ablation as first-line therapy (AAD-), and 83% had undergone at least one AAD trial (AAD+). In AAD- patients, the reasons for this strategy were: (i) patient preference, n= 51 (71%); (ii) contra-indication to AAD, n= 21 (29%). Atrial fibrillation duration prior to ablation was shorter (52 ± 54 vs. 78 ± 81 months, P= 0.005), and the percentage of patients hospitalized for AF (32% vs. 48%, P= 0.01) was lower in AAD- patients. Long-term multiple procedure success rate (78% vs. 64%, P= 0.03) was higher in the AAD- group, and there were less repeat ablations in this group (21% vs. 38%, P= 0.01).

CONCLUSION

Catheter ablation was first-line therapy of AF in a significant number of patients, according either to patient preference or to medical factors, and this had important implications. Ablative therapy was performed at an earlier stage of the disease, and was associated with a significantly higher success rate and with a decreased need for repeat procedures.

Total costs and atrial fibrillation ablation success or failure in Medicare-aged patients in the United States

INTRODUCTION

This retrospective cohort study compared the direct medical costs of successful versus unsuccessful catheter ablation in Medicare-aged patients with atrial fibrillation (AF), using medical claims data.

METHODS

AF patients with > or = 12 months of continuous medical/pharmacy coverage pre- and postablation were identified from the MarketScan Medicare database (January 2003 to December 2006). For study inclusion, patients were required to have > or = 2 AF inpatient/outpatient visits within 6 months and to have received antiarrhythmic drug therapy within 12 months prior to the index ablation. Ablation success was defined as the absence of antiarrhythmic drug therapy 6-12 months postablation.

RESULTS

Of 135 patients identified (67% men, mean age 73 years), ablation was successful in 69 (51.1%); most patients (96%) underwent a single procedure. Patients with successful ablation discontinued antiarrhythmic drug treatment after (mean) 54 days. Use of rate-control and anticoagulant drugs decreased after successful ablation, from 87% to 67% and from 86% to 64% of patients, respectively. Among failed ablation patients, 74% versus 70% received rate-control drugs, and 88% versus 82% received anticoagulants pre- versus postablation. Mean +/- SD per-patient procedural costs were $13,655+/-$12,761 for successful compared with $17,294+/-$26,502 (P=0.21) for failed ablation, while AF-related medical costs over 12 months postablation were $2394+/-$642 and $2703+/-$1706, respectively (P<0.001). Overall costs tended to be lower for successful ($16,049+/-$12,536) than for failed ($19,997+/-$13,958) AF ablation (P=0.07). These findings are subject to the limitations imposed by a retrospective database analysis and a small sample size.

CONCLUSION

Outside the clinical-trial setting, catheter ablation for second-line treatment of AF proved unsuccessful in half of Medicare-aged patients. Direct medical costs did not differ significantly between patients with failed and successful ablations. The high rate and costs of AF ablation failure in the Medicare-aged population reinforce the need for better understanding of prognostic factors for ablation outcome.

Is AF Ablation Cost Effective?

The use of catheter ablation to treat AF is increasing rapidly, but there is presently an incomplete understanding of its cost-effectiveness. AF ablation procedures involve significant up-front expenditures, but multiple randomized trials have demonstrated that ablation is more effective than antiarrhythmic drugs at maintaining sinus rhythm in a second-line and possibly first-line rhythm control setting. Although truly long-term data are limited, ablation, as compared with antiarrrhythmic drugs, also appears associated with improved symptoms and quality of life and a reduction in downstream hospitalization and other health care resource utilization. Several groups have developed cost effectiveness models comparing AF ablation primarily to antiarrhythmic drugs and the model results suggest that ablation likely falls within the range generally accepted as cost-effective in developed nations. This paper will review available information on the cost-effectiveness of catheter ablation for the treatment of atrial fibrillation, and discuss continued areas of uncertainty where further research is required.

Novel approaches for the surgical treatment of atrial fibrillation: time for a guideline revision?

Atrial fibrillation is a major health problem in Western countries, and is associated with considerable morbidity and resource consumption. Safe and reliable surgical techniques for the termination of this arrhythmia have been developed since the time of the original Cox "maze I" procedure. Novel equipment based on radiofrequency and microwave technologies can be employed to create transmural atrial lesions, even in the context of minimally invasive surgery to the atrioventricular valves via right minithoracotomy. The aim of this paper is to review the recent literature on this approach, and the clinical results in terms of arrhythmia termination and postoperative morbidity. With the aim to substantiate the practice of a simple, yet reliable, surgical ablation during minimally invasive heart valve surgery, we discuss the results of different patterns of atrial lesions having different degrees of surgical complexity. Finally, minimally invasive epicardial ablation for lone atrial fibrillation represents an emerging surgical indication. The results of state-of-the-art transcatheter ablation represent now its benchmark of comparison.