Atrial flutter and atrial fibrillation ablation - sequential or combined? A cost-benefit and risk analysis of primary prevention pulmonary vein ablation

作者：Gula Lorne J^*; Skanes Allan C; Klein George J; Jenkyn Krista B; Redfearn Damian P; Manlucu Jaimie; Roberts Jason D; Yee Raymond; Tang Anthony S L; Leong Sit Peter

来源：Heart Rhythm, 2016, 13(7): 1441-1448.

DOI：10.1016/j.hrthm.2016.02.018

• Atrial fibrillation
• Pulmonary vein isolation
• Cost modeling
• Risk
• Decision analysis

BACKGROUND Recent studies have tested the hypothesis that preventive pulmonary vein isolation (PVI) at time of atrial flutter ablation in patients who have not had atrial fibrillation (AF) will reduce future incidence of AF.
OBJECTIVE To model relative procedural costs, risks, and benefits of sequential versus combined ablation strategies.
METHODS The decision model compares a sequential ablation strategy of atrial flutter ablation, followed by future PVI if necessary, with an initial combined flutter and preventive PVI ablation strategy. Assumptions are AF incidence 20% per year, PVI success rate 70%, PVI complication rate 4%, atrial flutter complication rate 10/0, and costs $13,056 for PVI and $8,466 for atrial flutter ablation.
RESULTS The sequential ablation strategy is less expensive, at 1.4 vs 1.6 expected flutter ablation equivalents (FAE) ($11,852 vs $13,545) per patient, and entails less average risk, at 2% vs 4%. A combined ablation strategy is more expensive if the relative cost of PVI is more than 24.6% higher than atrial flutter ablation. A combined ablation strategy has higher total risk if PVI procedural risk is 24.6% more than atrial flutter ablation.
CONCLUSIONS Under base case assumptions of relative cost of PVI to flutter ablation 1.5 and relative risk 4, a sequential ablation approach has less total expected cost and less expected risk. There appears to be no compelling reason to adopt a combined ablation approach into standard practice. Nomograms are presented to allow the reader to assess which strategy is preferred according to local relative costs and risk.

• 出版日期2016-7