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Chander S, Kumari R, Luhana S, Shiwlani S, Parkash O, Sorath F, Wang HY, Tan S, Rahaman Z, Mohammed YN, Lohana AC, Sakshi F, Vaish E, Sadarat F. Antiarrhythmic drug therapy and catheter ablation in patients with paroxysmal or persistent atrial fibrillation: a systematic review and meta-analysis. BMC Cardiovasc Disord 2024; 24:321. [PMID: 38918704 PMCID: PMC11197351 DOI: 10.1186/s12872-024-03983-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 06/17/2024] [Indexed: 06/27/2024] Open
Abstract
BACKGROUND Catheter ablation and antiarrhythmic drug therapy are utilized for rhythm control in atrial fibrillation (AF), but their comparative effectiveness, especially with contemporary treatment modalities, remains undefined. We conducted a systematic review and meta-analysis contrasting current ablation techniques against antiarrhythmic medications for AF. METHODS We searched PubMed, SCOPUS, Cochrane CENTRAL, and Web of Science until November 2023 for randomized trials comparing AF catheter ablation with antiarrhythmics, against antiarrhythmic drug therapy alone, reporting outcomes for > 6 months. Four investigators extracted data and appraised risk of bias (ROB) with ROB 2 tool. Meta-analyses estimated pooled efficacy and safety outcomes using R software. RESULTS Twelve trials (n = 3977) met the inclusion criteria. Catheter ablation was associated with lower AF recurrence (relative risk (RR) = 0.44, 95%CI (0.33, 0.59), P ˂ 0.0001) and hospitalizations (RR = 0.44, 95%CI (0.23, 0.82), P = 0.009) than antiarrhythmic medications. Catheter ablation also improved the physical quality of life component score (assessed by a 36-item Short Form survey) by 7.61 points (95%CI -0.70-15.92, P = 0.07); but, due to high heterogeneity, it was not statistically significant. Ablation was significantly associated with higher procedural-related complications [RR = 15.70, 95%CI (4.53, 54.38), P < 0.0001] and cardiac tamponade [RR = 9.22, 95%CI (2.16, 39.40), P = 0.0027]. All-cause mortality was similar between the two groups. CONCLUSIONS For symptomatic AF, upfront catheter ablation reduces arrhythmia and hospitalizations better than continued medical therapy alone, albeit with moderately more adverse events. Careful patient selection and risk-benefit assessment are warranted regarding the timing of ablation.
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Affiliation(s)
- Subhash Chander
- Department of Medicine, Icahn School of Medicine, Mount Sinai Beth Israel Hospital, New York City, NY, USA.
| | - Roopa Kumari
- Department of Medicine, Icahn School of Medicine, Mount Sinai Beth Israel Hospital, New York City, NY, USA
| | - Sindhu Luhana
- Department of Medicine, Icahn School of Medicine, Mount Sinai Beth Israel Hospital, New York City, NY, USA
| | - Sheena Shiwlani
- Department of Medicine, Icahn School of Medicine, Mount Sinai Beth Israel Hospital, New York City, NY, USA
| | - Om Parkash
- Department of Medicine, Montefiore Medical Centre, Wakefield, NY, USA
| | - Fnu Sorath
- Department of Anesthesiology, Dow University Health Sciences, Karachi, Pakistan
| | - Hong Yu Wang
- Department of Medicine, Icahn School of Medicine, Mount Sinai Beth Israel Hospital, New York City, NY, USA
| | - Sam Tan
- Department of Medicine, Icahn School of Medicine, Mount Sinai Beth Israel Hospital, New York City, NY, USA
| | - Zubair Rahaman
- Department of Medicine, University at Buffalo, Buffalo, NY, USA
| | | | - Abhi Chand Lohana
- Department of Medicine, WVU, Camden Clark Medical Centre, Parkersburg, WV, USA
| | - Fnu Sakshi
- Department of Medicine, Piedmont Augusta Hospital, Augusta, GA, USA
| | - Esha Vaish
- Department of Medicine, Icahn School of Medicine, Mount Sinai Beth Israel Hospital, New York City, NY, USA
| | - Fnu Sadarat
- Department of Medicine, University at Buffalo, Buffalo, NY, USA
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Zenger B, Li H, Bunch TJ, Crawford C, Fang JC, Groh CA, Hess R, Navaravong L, Ranjan R, Young J, Zhang Y, Steinberg BA. Major drivers of healthcare system costs and cost variability for routine atrial fibrillation ablation. Heart Rhythm O2 2023; 4:251-257. [PMID: 37124552 PMCID: PMC10134392 DOI: 10.1016/j.hroo.2022.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background Catheter ablation is an effective treatment for atrial fibrillation (AF) but incurs significant financial costs to payers. Reducing variability may improve cost effectiveness. Objectives We aimed to measure (1) the components of direct and indirect costs for routine AF ablation procedures, (2) the variability of those costs, and (3) the main factors driving ablation cost variability. Methods Using data from the University of Utah Health Value Driven Outcomes system, we were able to measure direct, inflation-adjusted costs of uncomplicated, routine AF ablation to the healthcare system. Direct costs were considered costs incurred by pharmacy, disposable supplies, patient labs, implants, and other services categories (primarily anesthesia support) and indirect costs were considered within imaging, facility, and electrophysiology lab management categories. Results A total of 910 patients with 1060 outpatient ablation encounters were included from January 1, 2013, to December 31, 2020. Disposable supplies accounted for the largest component of cost with 44.8 ± 9.7%, followed by other services (primarily anesthesia support) with 30.4 ± 7.7% and facility costs with 16.1 ± 5.6%; pharmacy, imaging, and implant costs each contributed <5%. Direct costs were larger than indirect costs (82.4 ± 5.6% vs 17.6 ± 5.6%). Multivariable regression showed that procedure operator was the primary factor associated with AF ablation overall cost (up to 12% differences depending on operator). Conclusions Direct costs and other services (primarily anesthesia) drive the majority costs associated with AF ablations. There is significant variability in costs for these routine, uncomplicated AF ablation procedures. The procedure operator, and not patient characteristic, is the main driver for cost variability.
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Affiliation(s)
- Brian Zenger
- University of Utah School of Medicine, Salt Lake City, Utah
| | - Haojia Li
- Department of Internal Medicine, Division of Epidemiology, University of Utah, Salt Lake City, Utah
| | - T. Jared Bunch
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Candice Crawford
- Decision Support, University of Utah Health, Salt Lake City, Utah
| | - James C. Fang
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Christopher A. Groh
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Rachel Hess
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah
| | - Leenhapong Navaravong
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Ravi Ranjan
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Jeff Young
- Decision Support, University of Utah Health, Salt Lake City, Utah
| | - Yue Zhang
- Department of Internal Medicine, Division of Epidemiology, University of Utah, Salt Lake City, Utah
| | - Benjamin A. Steinberg
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
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Kim W, Kim M, Kim YT, Park W, Kim JB, Kim C, Joung B. Cost-effectiveness of rhythm control strategy: Ablation versus antiarrhythmic drugs for treating atrial fibrillation in Korea based on real-world data. Front Cardiovasc Med 2023; 10:1062578. [PMID: 36760559 PMCID: PMC9902500 DOI: 10.3389/fcvm.2023.1062578] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 01/09/2023] [Indexed: 01/26/2023] Open
Abstract
Background Ablation-based treatment has emerged as an alternative rhythm control strategy for symptomatic atrial fibrillation (AF). Recent studies have demonstrated the cost-effectiveness of ablation compared with medical therapy in various circumstances. We assessed the economic comparison between ablation and medical therapy based on a nationwide real-world population. Methods and findings For 192,345 patients with new-onset AF (age ≥ 18 years) identified between August 2015 and July 2018 from the Korean Health Insurance Review and Assessment Service (HIRA) database, medical resource use data were collected to compare AF patients that underwent ablation (N = 2,131) and those administered antiarrhythmic drugs (N = 8,048). Subsequently, a Markov chain Monte Carlo model was built. The patients had at least one risk factor for stroke, and the base-case used a 20-year time horizon, discounting at 4.5% annually. Transition probabilities and costs were estimated using the present data, and utilities were derived from literature review. The costs were converted to US $ (2019). Sensitivity analyses were performed using probabilistic and deterministic methods. The net costs and quality-adjusted life years (QALY) for antiarrhythmic drugs and ablation treatments were $37,421 and 8.8 QALYs and $39,820 and 9.3 QALYs, respectively. Compared with antiarrhythmic drugs, incremental cost-effectiveness ratio of ablation was $4,739/QALY, which is lower than the willingness-to-pay (WTP) threshold of $32,000/QALY. Conclusion In symptomatic AF patients with a stroke risk under the age of 75 years, ablation-based rhythm control is potentially a more economically attractive option compared with antiarrhythmic drug-based rhythm control in Korea.
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Affiliation(s)
- Woojin Kim
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Min Kim
- Division of Cardiology, Department of Internal Medicine, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Yun Tae Kim
- Department of Public Health, Yonsei University Graduate School, Seoul, Republic of Korea
| | - Woongbi Park
- Department of Public Health, Yonsei University Graduate School, Seoul, Republic of Korea
| | - Jin-bae Kim
- Division of Cardiology, Department of Internal Medicine, Kyung Hee University Hospital, Seoul, Republic of Korea,*Correspondence: Jin-bae Kim,
| | - Changsoo Kim
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea,Institute of Human Complexity and Systems Science, Yonsei University, Incheon, Republic of Korea,Changsoo Kim,
| | - Boyoung Joung
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea,Boyoung Joung,
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Hu M, Han Y, Zhao W, Chen W. Long-Term Cost-Effectiveness Comparison of Catheter Ablation and Antiarrhythmic Drugs in Atrial Fibrillation Treatment Using Discrete Event Simulation. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022; 25:975-983. [PMID: 35667785 DOI: 10.1016/j.jval.2021.10.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 09/02/2021] [Accepted: 10/25/2021] [Indexed: 06/15/2023]
Abstract
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.
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Affiliation(s)
- Min Hu
- School of Public Health, Fudan University, Shanghai, China
| | - Yi Han
- Health Economics Research Institute, Sun Yat-sen University, Guangzhou, China
| | - Wangyang Zhao
- School of Economics, Shanghai University of Finance and Economics, Shanghai, China
| | - Wen Chen
- School of Public Health, Fudan University, Shanghai, China.
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D'Souza S, Elshazly MB, Dargham SR, Donnellan E, Asaad N, Hayat S, Kanj M, Baranowski B, Wazni O, Saliba W, Abi Khalil C. Atrial fibrillation catheter ablation complications in obese and diabetic patients: Insights from the US Nationwide Inpatient Sample 2005-2013. Clin Cardiol 2021; 44:1151-1160. [PMID: 34132405 PMCID: PMC8364717 DOI: 10.1002/clc.23667] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 05/17/2021] [Accepted: 06/03/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Obesity and diabetes are risk factors for atrial fibrillation (AF) incidence and recurrence after catheter ablation. However, their impact on post-ablation complications in real-world practice is unknown. OBJECTIVES We examine annual trends in AF ablations and procedural outcomes in obese and diabetic patients in the US and whether obesity and diabetes are independently associated with adverse outcomes. METHODS Using the Nationwide Inpatient Sample (2005-2013), we identified obese and diabetic patients admitted for AF ablation. Common complications were identified using ICD-9-CM codes. The primary outcome included the composite of any in-hospital complication or death. Annual trends of the primary outcome, length-of-stay (LOS) and total-inflation adjusted hospital charges were examined. Multivariate analyses studied the association of obesity and diabetes with outcomes. RESULTS An estimated 106 462 AF ablations were performed in the US from 2005 to 2013. Annual trends revealed a gradual increase in ablations performed in obese and diabetic patients and in complication rates. The overall rate of the primary outcome in obese was 11.7% versus 8.2% in non-obese and 10.7% in diabetic versus 8.2% in non-diabetic patients (p < .001). CONCLUSIONS Obesity was independently associated with increased complications (adjusted OR, 95% CI:1.39, 1.20-1.62), longer LOS (1.36, 1.23-1.49), and higher charges (1.16, 1.12-1.19). Diabetes was only associated with longer LOS (1.27, 1.16-1.38). Obesity, but not diabetes, in patients undergoing AF ablation is an independent risk factor for immediate post-ablation complications and higher costs. Future studies should investigate whether weight loss prior to ablation reduces complications and costs.
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Affiliation(s)
- Shawn D'Souza
- Research DepartmentWeill Cornell Medicine‐QatarDohaQatar
| | - Mohamed B. Elshazly
- Research DepartmentWeill Cornell Medicine‐QatarDohaQatar
- Joan and Sanford I. Weill Department of MedicineWeill Cornell MedicineNew YorkNew YorkUSA
- Department of Cardiovascular MedicineThe Heart Hospital, Hamad Medical CorporationDohaQatar
| | - Soha R. Dargham
- Research DepartmentWeill Cornell Medicine‐QatarDohaQatar
- Biostatistics, Epidemiology, and Biomathematics Research CoreWeill Cornell Medicine‐QatarDohaQatar
| | - Eoin Donnellan
- Department of Cardiovascular MedicineHeart and Vascular Institute, Cleveland ClinicClevelandOhioUSA
| | - Nidal Asaad
- Research DepartmentWeill Cornell Medicine‐QatarDohaQatar
- Department of Cardiovascular MedicineThe Heart Hospital, Hamad Medical CorporationDohaQatar
| | - Sajjad Hayat
- Research DepartmentWeill Cornell Medicine‐QatarDohaQatar
- Department of Cardiovascular MedicineThe Heart Hospital, Hamad Medical CorporationDohaQatar
| | - Mohamed Kanj
- Department of Cardiovascular MedicineHeart and Vascular Institute, Cleveland ClinicClevelandOhioUSA
| | - Brian Baranowski
- Department of Cardiovascular MedicineHeart and Vascular Institute, Cleveland ClinicClevelandOhioUSA
| | - Oussama Wazni
- Department of Cardiovascular MedicineHeart and Vascular Institute, Cleveland ClinicClevelandOhioUSA
| | - Walid Saliba
- Department of Cardiovascular MedicineHeart and Vascular Institute, Cleveland ClinicClevelandOhioUSA
| | - Charbel Abi Khalil
- Research DepartmentWeill Cornell Medicine‐QatarDohaQatar
- Joan and Sanford I. Weill Department of MedicineWeill Cornell MedicineNew YorkNew YorkUSA
- Department of Cardiovascular MedicineThe Heart Hospital, Hamad Medical CorporationDohaQatar
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Lau D, Sandhu RK, Andrade JG, Ezekowitz J, So H, Klarenbach S. Cost-Utility of Catheter Ablation for Atrial Fibrillation in Patients with Heart Failure: An Economic Evaluation. J Am Heart Assoc 2021; 10:e019599. [PMID: 34238020 PMCID: PMC8483474 DOI: 10.1161/jaha.120.019599] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Recent trials comparing catheter ablation to medical therapy in patients with heart failure (HF) with symptomatic atrial fibrillation despite first-line management have demonstrated a reduction in adverse outcomes. We performed an economic evaluation to estimate the cost-utility of catheter ablation as second line therapy in patients with HF with reduced ejection fraction. Methods and Results A Markov model with health states of alive, dead, and alive with amiodarone toxicity was constructed, using the perspective of the Canadian healthcare payer. Patients in the alive states were at risk of HF and non-HF hospitalizations. Parameters were obtained from randomized trials and Alberta health system data for costs and outcomes. A lifetime time horizon was adopted, with discounting at 3.0% annually. Probabilistic and 1-way sensitivity analyses were performed. Costs are reported in 2018 Canadian dollars. A patient treated with catheter ablation experienced lifetime costs of $64 960 and 5.63 quality-adjusted life-years (QALY), compared with $49 865 and 5.18 QALYs for medical treatment. The incremental cost-effectiveness ratio was $35 360/QALY (95% CI, $21 518-77 419), with a 90% chance of being cost-effective at a willingness-to-pay threshold of $50 000/QALY. A minimum mortality reduction of 28%, or a minimum duration of benefit of >1 to 2 years was required for catheter ablation to be attractive at this threshold. Conclusions Catheter ablation is likely to be cost-effective as a second line intervention for patients with HF with symptomatic atrial fibrillation, with incremental cost-effectiveness ratio $35 360/QALY, as long as over half of the relative mortality benefit observed in extant trials is borne out in future studies.
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Affiliation(s)
- Darren Lau
- Department of Medicine University of Alberta Edmonton AB Canada
| | - Roopinder K Sandhu
- Mazankowski Alberta Heart InstituteUniversity of Alberta Edmonton AB Canada.,Canadian VIGOUR Centre University of Alberta Edmonton AB Canada
| | - Jason G Andrade
- Division of Cardiology University of British Columbia Vancouver BC Canada
| | - Justin Ezekowitz
- Mazankowski Alberta Heart InstituteUniversity of Alberta Edmonton AB Canada.,Canadian VIGOUR Centre University of Alberta Edmonton AB Canada
| | - Helen So
- Department of Medicine University of Alberta Edmonton AB Canada
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Heijman J, Sutanto H, Crijns HJGM, Nattel S, Trayanova NA. Computational models of atrial fibrillation: achievements, challenges, and perspectives for improving clinical care. Cardiovasc Res 2021; 117:1682-1699. [PMID: 33890620 PMCID: PMC8208751 DOI: 10.1093/cvr/cvab138] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Indexed: 12/11/2022] Open
Abstract
Despite significant advances in its detection, understanding and management, atrial fibrillation (AF) remains a highly prevalent cardiac arrhythmia with a major impact on morbidity and mortality of millions of patients. AF results from complex, dynamic interactions between risk factors and comorbidities that induce diverse atrial remodelling processes. Atrial remodelling increases AF vulnerability and persistence, while promoting disease progression. The variability in presentation and wide range of mechanisms involved in initiation, maintenance and progression of AF, as well as its associated adverse outcomes, make the early identification of causal factors modifiable with therapeutic interventions challenging, likely contributing to suboptimal efficacy of current AF management. Computational modelling facilitates the multilevel integration of multiple datasets and offers new opportunities for mechanistic understanding, risk prediction and personalized therapy. Mathematical simulations of cardiac electrophysiology have been around for 60 years and are being increasingly used to improve our understanding of AF mechanisms and guide AF therapy. This narrative review focuses on the emerging and future applications of computational modelling in AF management. We summarize clinical challenges that may benefit from computational modelling, provide an overview of the different in silico approaches that are available together with their notable achievements, and discuss the major limitations that hinder the routine clinical application of these approaches. Finally, future perspectives are addressed. With the rapid progress in electronic technologies including computing, clinical applications of computational modelling are advancing rapidly. We expect that their application will progressively increase in prominence, especially if their added value can be demonstrated in clinical trials.
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Affiliation(s)
- Jordi Heijman
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Faculty of Health, Medicine, and Life Sciences, Maastricht University, PO Box 616, 6200 MD Maastricht, The Netherlands
| | - Henry Sutanto
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Faculty of Health, Medicine, and Life Sciences, Maastricht University, PO Box 616, 6200 MD Maastricht, The Netherlands
| | - Harry J G M Crijns
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Faculty of Health, Medicine, and Life Sciences, Maastricht University, PO Box 616, 6200 MD Maastricht, The Netherlands
| | - Stanley Nattel
- Department of Medicine, Montreal Heart Institute and Université de Montréal, Montreal, Canada
- Department of Pharmacology and Therapeutics, McGill University, Montreal, Canada
- Institute of Pharmacology, West German Heart and Vascular Center, Faculty of Medicine, University Duisburg-Essen, Duisburg, Germany
- IHU Liryc and Fondation Bordeaux Université, Bordeaux, France
| | - Natalia A Trayanova
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, and Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Abstract
AF is the most common arrhythmia in clinical practice. In addition to the severe effect on quality of life, patients with AF are at higher risk of stroke and mortality. Recent studies have suggested that atrial and ventricular substrate play a major role in the development and maintenance of AF. Cardiac MRI has emerged as a viable tool for interrogating the underlying substrate in AF patients. Its advantage includes localisation and quantification of structural remodelling. Cardiac MRI of the atrial substrate is not only a tool for management and treatment of arrhythmia, but also to individualise the prevention of stroke and major cardiovascular events. This article provides an overview of atrial imaging using cardiac MRI and its clinical implications in the AF population.
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Affiliation(s)
- Yan Zhao
- Tulane Research Innovation for Arrhythmia Discoveries (TRIAD), Heart and Vascular Institute, Tulane University School of Medicine, LA, US
| | - Lilas Dagher
- Tulane Research Innovation for Arrhythmia Discoveries (TRIAD), Heart and Vascular Institute, Tulane University School of Medicine, LA, US
| | - Chao Huang
- Tulane Research Innovation for Arrhythmia Discoveries (TRIAD), Heart and Vascular Institute, Tulane University School of Medicine, LA, US
| | - Peter Miller
- Tulane Research Innovation for Arrhythmia Discoveries (TRIAD), Heart and Vascular Institute, Tulane University School of Medicine, LA, US
| | - Nassir F Marrouche
- Tulane Research Innovation for Arrhythmia Discoveries (TRIAD), Heart and Vascular Institute, Tulane University School of Medicine, LA, US
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Field ME, Gold MR, Rahman M, Goldstein L, Maccioni S, Srivastava A, Khanna R, Piccini JP, Friedman DJ. Healthcare utilization and cost in patients with atrial fibrillation and heart failure undergoing catheter ablation. J Cardiovasc Electrophysiol 2020; 31:3166-3175. [PMID: 33022815 PMCID: PMC7821325 DOI: 10.1111/jce.14774] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 09/21/2020] [Accepted: 09/25/2020] [Indexed: 01/15/2023]
Abstract
Background Catheter ablation is an effective treatment for patients with atrial fibrillation (AF) and heart failure (HF). However, little is known about how healthcare utilization and cost change after ablation in this population. We sought to determine healthcare utilization and cost patterns among patients with AF and HF undergoing ablation. Methods Using a large United States administrative database, we identified (n = 1568) treated with ablation with a primary and secondary diagnosis of AF and HF, respectively, were evaluated 1‐year pre‐ and postablation for outcomes including inpatient admissions (AF or HF), emergency department (ED) visits, cardioversions, length of stay (LOS), and cost. A secondary analysis was extended to 3‐years postablation. Results Reductions were observed in AF‐related admissions (64%), LOS (65%), cardioversions (52%), ED visits (51%, all values, p < .0001), and HF‐related admissions (22%, p = .01). There was a 40% reduction in inpatient admission cost ($4165 preablation to $2510 postablation, p < .0001). In a sensitivity analysis excluding repeat‐ablation patients, a greater reduction in overall AF management cost was observed compared to the full cohort (−43% vs. −2%). Comparing 1‐year pre‐ to 3‐years postablation, both total mean AF‐management cost ($850 per‐patient per‐month 1‐year pre‐ to $546 3‐years postablation, p < .0001) and AF‐related healthcare utilization was reduced. Conclusions Catheter ablation in patients with AF and HF resulted in significant reductions in healthcare utilization and cost through 3‐years of follow‐up. This reduction was observed regardless of whether repeat ablation was performed, reflecting the positive impact of ablation on longer term cost reduction.
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Affiliation(s)
- Michael E Field
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Michael R Gold
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Motiur Rahman
- Medical Device Epidemiology, Johnson and Johnson, New Brunswick, New Jersey, USA
| | - Laura Goldstein
- Franchise Health Economics and Market Access, Johnson & Johnson Medical Devices, Irvine, California, USA
| | | | | | - Rahul Khanna
- Medical Device Epidemiology, Johnson and Johnson, New Brunswick, New Jersey, USA
| | - Jonathan P Piccini
- Division of Cardiology, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Daniel J Friedman
- Division of Cardiology, Yale School of Medicine, New Haven, Connecticut, USA
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10
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Burkman G, Naccarelli GV. Rhythm Control of Atrial Fibrillation in Heart Failure with Reduced Ejection Fraction. Curr Cardiol Rep 2020; 22:83. [DOI: 10.1007/s11886-020-01336-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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11
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Sanchez JM, Shah R, Kouassi Y, Chronowic M, Wilson L, Marcus GM. A cost‐effectiveness analysis comparing a conventional mechanical needle to a radiofrequency device for transseptal punctures. J Cardiovasc Electrophysiol 2020; 31:1672-1677. [DOI: 10.1111/jce.14500] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 04/10/2020] [Accepted: 04/14/2020] [Indexed: 11/27/2022]
Affiliation(s)
- José M. Sanchez
- Section of Cardiac Electrophysiology, Division of Cardiology University of California San Francisco California
| | - Rahil Shah
- Department of Clinical Pharmacy University of California San Francisco California
| | - Yao Kouassi
- Department of Clinical Pharmacy University of California San Francisco California
| | | | - Leslie Wilson
- Department of Clinical Pharmacy University of California San Francisco California
| | - Gregory M. Marcus
- Section of Cardiac Electrophysiology, Division of Cardiology University of California San Francisco California
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Chen Y, Gomes M, Garcia JV, Hunter RJ, Chow AW, Dhinoja M, Schilling RJ, Lowe M, Lambiase PD. Cost-effectiveness of ablation of ventricular tachycardia in ischaemic cardiomyopathy: limitations in the trial evidence base. Open Heart 2020; 7:e001155. [PMID: 32076562 PMCID: PMC6999675 DOI: 10.1136/openhrt-2019-001155] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 09/12/2019] [Accepted: 10/14/2019] [Indexed: 11/10/2022] Open
Abstract
Objective Catheter ablation is an important treatment for ventricular tachycardia (VT) that reduces the frequency of episodes of VT. We sought to evaluate the cost-effectiveness of catheter ablation versus antiarrhythmic drug (AAD) therapy. Methods A decision-analytic Markov model was used to calculate the costs and health outcomes of catheter ablation or AAD treatment of VT for a hypothetical cohort of patients with ischaemic cardiomyopathy and an implantable cardioverter-defibrillator. The health states and input parameters of the model were informed by patient-reported health-related quality of life (HRQL) data using randomised clinical trial (RCT)-level evidence wherever possible. Costs were calculated from a 2018 UK perspective. Results Catheter ablation versus AAD therapy had an incremental cost-effectiveness ratio (ICER) of £144 150 (€161 448) per quality-adjusted life-year gained, over a 5-year time horizon. This ICER was driven by small differences in patient-reported HRQL between AAD therapy and catheter ablation. However, only three of six RCTs had measured patient-reported HRQL, and when this was done, it was assessed infrequently. Using probabilistic sensitivity analyses, the likelihood of catheter ablation being cost-effective was only 11%, assuming a willingness-to-pay threshold of £30 000 used by the UK’s National Institute for Health and Care Excellence. Conclusion Catheter ablation of VT is unlikely to be cost-effective compared with AAD therapy based on the current randomised trial evidence. However, better designed studies incorporating detailed and more frequent quality of life assessments are needed to provide more robust and informed cost-effectiveness analyses.
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Affiliation(s)
- Yang Chen
- Cardiology, Barts Health NHS Trust, London, UK.,Institute of Cardiovascular Science, University College London, London, UK
| | - Manuel Gomes
- Department of Applied Health Research, University College London, London, UK
| | | | | | | | | | | | - Martin Lowe
- Cardiology, Barts Health NHS Trust, London, UK
| | - Pier D Lambiase
- Cardiology, Barts Health NHS Trust, London, UK.,Institute of Cardiovascular Science, University College London, London, UK
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Martinek M, Pürerfellner H, Blessberger H, Pruckner G. Impact of catheter ablation therapy for atrial fibrillation on healthcare expenditures in a middle European cohort. Europace 2020; 22:576-583. [DOI: 10.1093/europace/euz362] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 12/13/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
Aims
Atrial fibrillation (AF) is the most prevalent arrhythmia in western countries. It is associated with increased mortality and morbidity and responsible for hospitalization rates of 10–40% per patient per year. Studies from the UK and the USA have shown that AF is responsible for ∼1% of the total healthcare expenditures in these countries. The only potentially curative treatment is pulmonary vein isolation (PVI). Published health economic data on the impact of PVI mainly consist of simulations of expenditures with assumed efficacy taken from ablation studies. Real expenditure data are missing as well as pre-ablation period data and long-term data.
Methods and results
We analyse true healthcare expenditures based on inpatient and outpatient data from the Upper Austrian Health Insurance Fund social security system of patients undergoing PVI during 2005 to 2015. We identified 1135 patients undergoing PVI with 268 having multiple procedures. Days of hospitalization and days of sick leave started to rise in the year before ablation. PVI was able to lower both parameters to the level of 1 year before ablation. Comparing four quarters before and after a single-index ablation, a highly significant reduction in inpatient healthcare expenditures was documented. There was a significant, but numerically small increase in outpatient expenditures, resulting in a significant reduction in overall healthcare expenditures.
Conclusion
Analysing a cohort of the Upper Austrian Health Insurance Fund undergoing PVI, we found significant cost-saving effects on post-interventional healthcare expenditures and a reduction in days of sick leave.
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Affiliation(s)
- Martin Martinek
- Department of Internal Medicine II with Cardiology, Angiology, and Intensive Care Medicine, Ordensklinikum Linz GmbH, Elisabethinen, Fadingerstrasse 1, 4020 Linz, Austria
| | - Helmut Pürerfellner
- Department of Internal Medicine II with Cardiology, Angiology, and Intensive Care Medicine, Ordensklinikum Linz GmbH, Elisabethinen, Fadingerstrasse 1, 4020 Linz, Austria
| | - Hermann Blessberger
- Department of Cardiology and Intensive Care Medicine, Medical Faculty, Kepler University Hospital, Johannes Kepler University Linz, Linz, Austria
| | - Gerald Pruckner
- Institute of Health Economics, Johannes Kepler University Linz, Linz, Austria
- Christian Doppler Laboratory for Aging, Health, and the Labor Market, Johannes Kepler University Linz, Linz, Austria
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Prabhu S, Lim WH, Schilling RJ. The Evolving Role of Catheter Ablation in Patients With Heart Failure and AF. Arrhythm Electrophysiol Rev 2019; 8:47-53. [PMID: 30918667 PMCID: PMC6434504 DOI: 10.15420/aer.2019.9.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
AF and heart failure are emerging epidemics worldwide. Several recent trials have provided a growing evidence base for the benefits of catheter ablation in this patient group, which are yet to be universally adopted in clinical practice guidelines. This paper provides a summary of recent developments in this field and provides pragmatic advice to the treating physician regarding the appropriate role of catheter ablation in the overall management of patients with comorbid AF and heart failure.
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Affiliation(s)
- Sandeep Prabhu
- Department of Cardiac Electrophysiology, St Bartholomew’s Hospital, London, UK
| | - Wei H Lim
- Department of Cardiac Electrophysiology, St Bartholomew’s Hospital, London, UK
| | - Richard J Schilling
- Department of Cardiac Electrophysiology, St Bartholomew’s Hospital, London, UK
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Real-world outcomes, complications, and cost of catheter-based ablation for atrial fibrillation: an update. Curr Opin Cardiol 2018; 32:47-52. [PMID: 27755137 DOI: 10.1097/hco.0000000000000348] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Díaz-Martínez JC, Duque-Ramírez M, Marín-Velásquez JE, Aristizábal-Aristizábal JM, Velásquez-Vélez JE, Uribe-Arango W. Costos asociados a la fibrilación auricular. REVISTA COLOMBIANA DE CARDIOLOGÍA 2016. [DOI: 10.1016/j.rccar.2016.10.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Bhatt N, Turakhia M, Fogarty TJ. Cost-Effectiveness of Cardiac Radiosurgery for Atrial Fibrillation: Implications for Reducing Health Care Morbidity, Utilization, and Costs. Cureus 2016; 8:e720. [PMID: 27625906 PMCID: PMC5010376 DOI: 10.7759/cureus.720] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 08/01/2016] [Indexed: 01/08/2023] Open
Abstract
In the United States (U.S.), atrial fibrillation (AF) is the second-most common cardiovascular condition after hypertension, affecting four million Americans each year. Individuals with AF are three times more likely to be hospitalized over the span of a year when compared to medically matched control groups. The considerably large clinical population of individuals with AF mandates that the cost-effectiveness and efficacy of current treatment regimens for AF have egregious implications for health care spending and public health. Unfortunately, catheter ablation for AF treatment has been shown to make only modest gains in quality-adjusted life years, has yet to demonstrate cost-utility advantages over conventional therapies for AF, and has a reported rate of recurrence for AF that is notably high. Thus, there is a major unmet clinical need for a therapeutic option to treat AF that produces more consistent and efficacious results that are cost-effective. Cardiac radiosurgery as a therapy for AF has the potential to be remarkably cost-effective and produce robust patient outcomes. CyberHeart Inc. has developed the world's first-ever cardiac radiosurgery (CRS) system designed to ablate the heart non-invasively. Procedures that ablate the heart utilizing the Cyberheart CRS system are anticipated to allow higher efficacy and more consistent results than current techniques such as catheter ablation. The aim of this study is to present the current healthcare utilization and expenditures in AF treatment, report the cost-effectiveness of catheter ablation for AF, and project the potential cost-effectiveness of cardiac radiosurgery for the treatment of AF.
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Affiliation(s)
| | - Mintu Turakhia
- Department of Cardiology, Stanford University School of Medicine
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