Elsevier

American Heart Journal

Volume 231, January 2021, Pages 110-120
American Heart Journal

Clinical Investigation
Cost-effectiveness of combined catheter ablation and left atrial appendage closure for symptomatic atrial fibrillation in patients with high stroke and bleeding risk

https://doi.org/10.1016/j.ahj.2020.08.008Get rights and content

Background

Combined catheter ablation (CA) and left atrial appendage closure (LAAC) have been proposed for management of symptomatic atrial fibrillation (AF) in patients with high stroke and bleeding risk. We assessed the cost-effectiveness of combined CA and LAAC compared with CA and standard oral anticoagulation (OAC) in symptomatic AF.

Methods

A Markov model was developed to assess total costs, quality-adjusted life-years (QALYs), and the incremental cost-effectiveness ratio among 2 post-CA strategies: (1) standard OAC and (2) LAAC (combined CA and LAAC procedure). The base-case used a 10-year time horizon and consisted of a hypothetical cohort of patients aged 65 years with symptomatic AF, with high thrombotic (CHA2DS2-VASc = 3) and bleeding risk (HAS-BLED = 3), and planned for AF ablation. Values for transition probabilities, utilities, and costs were derived from the literature. Costs were converted to 2020 US dollars. Half-cycle correction was applied, and costs and QALYs were discounted at 3% annually. Sensitivity analyses were performed for significant variables and scenario analyses for higher embolic risk.

Results

In the base-case cohort of 10,000 patients followed for 10 years, total costs for the LAAC strategy were $29,027 and for OAC strategy were $27,896. The LAAC strategy was associated with 122 fewer disabling strokes and 203 fewer intracranial hemorrhages per 10,000 patients compared with the OAC strategy. The LAAC strategy had an incremental cost-effectiveness ratio of $11,072/QALY. In sensitivity analyses, although cost-effectiveness was highly dependent on the risk of intracranial hemorrhage in the LAAC strategy and the cost of the combined procedure, LAAC was superior to OAC under the most circumstances. Scenario analyses demonstrated that the combined procedure was more cost-effective in patients with higher stroke risk.

Conclusions

In symptomatic AF patients with high stroke and bleeding risk who are planned for CA, the combined CA and LAAC procedure may be a cost-effective therapeutic option and be more beneficial to patients with CHA2DS2-VASc risk score ≥3.

Section snippets

Decision model

Our base case consisted of a hypothetical cohort of patients aged 65 years with symptomatic AF planned for AF ablation, a CHA2DS2-VASc score of 3, and high bleeding risk (HAS-BLED score of 3) but without contraindications to OAC therapy. A simplified presentation of the model structure and patient pathway is depicted in Figure 1. The post-AF ablation strategies were as follows:

  • 1.

    Standard OAC strategy: the standard OAC therapy with nonwarfarin oral anticoagulants (NOACs) (dabigatran, rivaroxaban,

Base-case analysis

In the base-case cohort of 10,000 patients followed for 10 years, total costs for the LAAC strategy were US $29,027 and for OAC strategy were US $27,896 (Table II). The LAAC strategy was associated with 122 fewer disabling strokes per 10,000 patients and 203 fewer ICH per 10,000 patients compared with the OAC strategy (Table III). Thus, the LAAC strategy was more effective but with higher total costs, which resulted in an ICER of US $11,072/QALY. High upfront costs for the combined LAAC

Discussion

This analysis suggests that the combined CA and LAAC are a cost-effective therapeutic option for long-term stroke prevention in symptomatic AF patients planned for AF ablation with high stroke and bleeding risk (CHA2DS2-VASc score of 3 and HAS-BLED score of 3). Although deterministic sensitivity analysis demonstrated that cost-effectiveness was highly dependent on the LAAC relative risk of ICH and cost for combined procedure, the LAAC strategy was more cost-effective relative to the OAC

Conclusions

In symptomatic AF patients with high stroke and bleeding risk who are planned for CA, the combined CA and LAAC procedure may be a cost-effective therapeutic option, with more benefit to patients with CHA2DS2-VASc risk score ≥3.

Disclosures

K. P. has received fees for clinical proctorship, presentations, and advisory board participation from Boston Scientific, Medtronic, and Abbott.

References (44)

  • A.N. Shah et al.

    Long-term outcome following successful pulmonary vein isolation: pattern and prediction of very late recurrence

    J Cardiovasc Electrophysiol

    (2008)
  • M. Takigawa et al.

    Long-term follow-up after catheter ablation of paroxysmal atrial fibrillation: the incidence of recurrence and progression of atrial fibrillation

    Circ Arrhythm Electrophysiol

    (2014)
  • P. Kirchhof et al.

    2016 ESC guidelines for the management of atrial fibrillation developed in collaboration with EACTS

    Eur Heart J

    (2016)
  • P.G. Tepper et al.

    Real-world comparison of bleeding risks among non-valvular atrial fibrillation patients prescribed apixaban, dabigatran, or rivaroxaban

    PLoS One

    (2018)
  • G.Y.H. Lip et al.

    Discontinuation risk comparison among 'real-world' newly anticoagulated atrial fibrillation patients: apixaban, warfarin, dabigatran, or rivaroxaban

    PLoS One.

    (2018)
  • C.L. Baker et al.

    Comparison of drug switching and discontinuation rates in patients with nonvalvular atrial fibrillation treated with direct oral anticoagulants in the United States

    Adv Ther

    (2019)
  • Holmes DR, Reddy VY, Turi ZG, Doshi SK, Sievert H, Buchbinder M, Mullin CM and Sick P. Percutaneous closure of the left...
  • Phillips KPW, D.T.; Humphries, J.A.; et al. Combined catheter ablation for atrial fibrillation and Watchman® left...
  • L. Wintgens et al.

    Combined atrial fibrillation ablation and left atrial appendage closure: long-term follow-up from a large multicentre registry

    Europace

    (2018)
  • K.P. Phillips et al.

    Combining Watchman left atrial appendage closure and catheter ablation for atrial fibrillation: multicentre registry results of feasibility and safety during implant and 30 days follow-up

    Europace

    (2018)
  • B. Meier et al.

    EHRA/EAPCI expert consensus statement on catheter-based left atrial appendage occlusion

    Europace

    (2014)
  • T. Shiroiwa et al.

    International survey on willingness-to-pay (WTP) for one additional QALY gained: what is the threshold of cost effectiveness?

    Health Econ

    (2010)
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    • Actual management costs of patients with non-valvular atrial fibrillation treated with percutaneous left atrial appendage closure or oral anticoagulation

      2022, International Journal of Cardiology
      Citation Excerpt :

      Finally, because from our matched study it emerges that management costs of patients on OAC are significantly higher than management costs of patients after percutaneous LAAC, further investigations are necessary to clarify the potential net economic and clinical benefit that percutaneous LAAC could achieve in patients that are now treated with OAC only, according to international guidelines [3,4]. Future studies are also necessary to confirm (or refute) that, compared to OAC therapy, percutaneous LAAC is more cost effective, particularly in patients with higher risk for stroke [20]. To conclude, in our case-match study, percutaneous LAAC is an independent determinant to significantly reduce management costs of patients with non-valvular AF.

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    Funding sources: none.

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