Comparison of selective coronary angiography through the ablation catheter versus conventional coronary angiography to guide ablation of premature ventricular contractions originating from aortic cusp

BACKGROUND

Intraprocedural coronary angiography (CA) is recommended in patients undergoing ablation in aortic cusps to assess the relation of catheter tip and coronary ostia. In this report, we aimed to compare selective coronary angiography (SCA) through the contact force (CF)-sensing radiofrequency catheter with conventional coronary angiography (CCA) to guide ablation of premature ventricular contractions (PVC).

METHODS

This was a retrospective observational cohort study of prospectively collected data of 87 consecutive patients undergoing PVC ablation at a single institution between February 2016 and June 2021. Forty-six patients (53%) underwent SCA and forty-one patients (47%) underwent CCA. Data were consecutively collected case-by-case and entered into a computerized database. Procedural characteristics, complications, and clinical outcomes were compared between the SCA and CCA groups.

RESULTS

Successful ablation was achieved in seventy-seven (89%) patients. Total procedure and fluoroscopy time and radiation dose were significantly lower in SCA group (93 ± 22 min vs 102 ± 20 min, p = 0.042; 12 ± 3 min vs 14 ± 4 min, p = 0.030; 3292 ± 1221 μGy m² vs 3880 ± 1229 μGy m², p = 0.028, respectively). Median ambulation time was significantly longer in CCA group (6.8 ± 1 h vs 17.8 ± 1.8 h, p = 0.006).

CONCLUSIONS

Selective coronary angiography through the CF-sensing ablation catheter to assess the relation between the ablation site and the coronary ostia is feasible and safe. This technique precludes the requirement of an additional arterial access and decreases the total procedure and fluoroscopy time and radiation dose.

Evidence-based cardiovascular magnetic resonance cost-effectiveness calculator for the detection of significant coronary artery disease

BACKGROUND

Although prior reports have evaluated the clinical and cost impacts of cardiovascular magnetic resonance (CMR) for low-to-intermediate-risk patients with suspected significant coronary artery disease (CAD), the cost-effectiveness of CMR compared to relevant comparators remains poorly understood. We aimed to summarize the cost-effectiveness literature on CMR for CAD and create a cost-effectiveness calculator, useable worldwide, to approximate the cost-per-quality-adjusted-life-year (QALY) of CMR and relevant comparators with context-specific patient-level and system-level inputs.

METHODS

We searched the Tufts Cost-Effectiveness Analysis Registry and PubMed for cost-per-QALY or cost-per-life-year-saved studies of CMR to detect significant CAD. We also developed a linear regression meta-model (CMR Cost-Effectiveness Calculator) based on a larger CMR cost-effectiveness simulation model that can approximate CMR lifetime discount cost, QALY, and cost effectiveness compared to relevant comparators [such as single-photon emission computed tomography (SPECT), coronary computed tomography angiography (CCTA)] or invasive coronary angiography.

RESULTS

CMR was cost-effective for evaluation of significant CAD (either health-improving and cost saving or having a cost-per-QALY or cost-per-life-year result lower than the cost-effectiveness threshold) versus its relevant comparator in 10 out of 15 studies, with 3 studies reporting uncertain cost effectiveness, and 2 studies showing CCTA was optimal. Our cost-effectiveness calculator showed that CCTA was not cost-effective in the US compared to CMR when the most recent publications on imaging performance were included in the model.

CONCLUSIONS

Based on current world-wide evidence in the literature, CMR usually represents a cost-effective option compared to relevant comparators to assess for significant CAD.

Coronary Computed Tomography Angiography for Assesment of Stable Coronary Artery Disease – a Cost-effectiveness Perspective

Patients with chest pain presenting to the emergency room are currently investigated using either invasive coronary angiography (ICA) or noninvasive coronary computed tomography angiography (CCTA). ICA remains an expensive diagnostic tool and exposes patients to a high risk of periprocedural complication. Besides the currently available expansive economic evidence, there is still an important lingering issue: to establish, from the healthcare provider’s point of view, which is the most cost-effective investigation tool for the detection of significant coronary artery disease. The aim of this article is to present the latest developments in the field of imaging tools for the detection of coronary atherosclerosis in patients with chest pain, from the perspective of a cost-effectiveness analysis.

Reducing the cost of managing patients with atrial fibrillation undergoing percutaneous coronary intervention with stenting

Patients undergoing percutaneous coronary intervention (PCI) have an increased risk of both ischemic events and bleeding complications resulting from antithrombotic therapy. These events are particularly common in patients with a concomitant indication for oral anticoagulation, such as those with atrial fibrillation, and are associated with a substantial healthcare resource burden. Advances in procedural aspects of PCI have led to marked improvements in outcomes and a consequent reduction in the costs resulting from PCI-associated complications. Furthermore, recent randomized clinical trials have investigated the optimal antithrombotic strategy in the specific case of patients with atrial fibrillation undergoing PCI, leading to a shift toward the tailoring of antithrombotic therapy according to the patient's individual stroke and bleeding risks. Here we review these recent advances, with a particular focus on the improvements in antithrombotic strategies offered by the non-vitamin K antagonist oral anticoagulants.

Cost-effectiveness for imaging stable ischemic disease

Stable ischemic heart disease remains a major cause of morbidity and mortality. Although there are multiple imaging modalities to diagnose and/or assist in the clinical management, the most cost-effective approach remains unclear. We reviewed the relevant and recent evidence-based clinical studies and trials to suggest the most cost-effective approach to stable ischemic heart disease. The limitations of these studies are discussed. Incorporating the results of recent multicenter trials, we suggest that for appropriate patients with coronary artery disease with any degree of stenosis or presence of coronary calcium, optimal medical therapy may be most cost-effective. Invasive coronary angiography and/or coronary revascularization would be primarily for non-responders or >/=50% left main stenosis. Stress cardiac magnetic imaging would be performed for those patients with non-diagnostic coronary CT angiography from motion and non-responders from optimal medical therapy in non-diagnostic coronary CT angiography group from high coronary calcium. These paths seem to be safe and cost-effective but requires modeling for confirmation.

Cost-effectiveness analysis of stand-alone or combined non-invasive imaging tests for the diagnosis of stable coronary artery disease: results from the EVINCI study

AIM

This study aimed at evaluating the cost-effectiveness of different non-invasive imaging-guided strategies for the diagnosis of obstructive coronary artery disease (CAD) in a European population of patients from the Evaluation of Integrated Cardiac Imaging in Ischemic Heart Disease (EVINCI) study.

METHODS AND RESULTS

Cost-effectiveness analysis was performed in 350 patients (209 males, mean age 59 ± 9 years) with symptoms of suspected stable CAD undergoing computed tomography coronary angiography (CTCA) and at least one cardiac imaging stress-test prior to invasive coronary angiography (ICA) and in whom imaging exams were analysed at dedicated core laboratories. Stand-alone stress-tests or combined non-invasive strategies, when the first exam was uncertain, were compared. The diagnostic end-point was obstructive CAD defined as > 50% stenosis at quantitative ICA in the left main or at least one major coronary vessel. Effectiveness was defined as the percentage of correct diagnosis (cd) and costs were calculated using country-specific reimbursements. Incremental cost-effectiveness ratios (ICERs) were obtained using per-patient data and considering "no-imaging" as reference. The overall prevalence of obstructive CAD was 28%. Strategies combining CTCA followed by stress ECHO, SPECT, PET, or stress CMR followed by CTCA, were all cost-effective. ICERs values indicated cost saving from - 969€/cd for CMR-CTCA to - 1490€/cd for CTCA-PET, - 3092€/cd for CTCA-SPECT and - 3776€/cd for CTCA-ECHO. Similarly when considering early revascularization as effectiveness measure.

CONCLUSION

In patients with suspected stable CAD and low prevalence of disease, combined non-invasive strategies with CTCA and stress-imaging are cost-effective as gatekeepers to ICA and to select candidates for early revascularization.

Delayed enhancement cardiac computed tomography for the assessment of myocardial infarction: from bench to bedside

A large number of studies support the increasingly relevant prognostic value of the presence and extent of delayed enhancement (DE), a surrogate marker of fibrosis, in diverse etiologies. Gadolinium and iodinated based contrast agents share similar kinetics, thus leading to comparable myocardial characterization with cardiac magnetic resonance (CMR) and cardiac computed tomography (CT) at both first-pass perfusion and DE imaging. We review the available evidence of DE imaging for the assessment of myocardial infarction (MI) using cardiac CT (CTDE), from animal to clinical studies, and from 16-slice CT to dual-energy CT systems (DECT). Although both CMR and gadolinium agents have been originally deemed innocuous, a number of concerns (though inconclusive and very rare) have been recently issued regarding safety issues, including DNA double-strand breaks related to CMR, and gadolinium-associated nephrogenic systemic fibrosis and deposition in the skin and certain brain structures. These concerns have to be considered in the context of non-negligible rates of claustrophobia, increasing rates of patients with implantable cardiac devices, and a number of logistic drawbacks compared with CTDE, such as higher costs, longer scanning times, and difficulties to scan patients with impaired breath-holding capabilities. Overall, these issues might encourage the role of CTDE as an alternative for DE-CMR in selected populations.