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Hu Y, Gordon N, Ogg K, Kraitchman DL, Durr NJ, Surtees B. Thermal Characterization and Preclinical Feasibility Verification of an Accessible, Carbon Dioxide-Based Cryotherapy System. Bioengineering (Basel) 2024; 11:391. [PMID: 38671812 PMCID: PMC11048087 DOI: 10.3390/bioengineering11040391] [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] [Received: 03/01/2024] [Revised: 04/05/2024] [Accepted: 04/12/2024] [Indexed: 04/28/2024] Open
Abstract
To investigate the potential of an affordable cryotherapy device for the accessible treatment of breast cancer, the performance of a novel carbon dioxide-based device was evaluated through both benchtop testing and an in vivo canine model. This novel device was quantitatively compared to a commercial device that utilizes argon gas as the cryogen. The thermal behavior of each device was characterized through calorimetry and by measuring the temperature profiles of iceballs generated in tissue phantoms. A 45 min treatment in a tissue phantom from the carbon dioxide device produced a 1.67 ± 0.06 cm diameter lethal isotherm that was equivalent to a 7 min treatment from the commercial argon-based device, which produced a 1.53 ± 0.15 cm diameter lethal isotherm. An in vivo treatment was performed with the carbon dioxide-based device in one spontaneously occurring canine mammary mass with two standard 10 min freezes. Following cryotherapy, this mass was surgically resected and analyzed for necrosis margins via histopathology. The histopathology margin of necrosis from the in vivo treatment with the carbon dioxide device at 14 days post-cryoablation was 1.57 cm. While carbon dioxide gas has historically been considered an impractical cryogen due to its low working pressure and high boiling point, this study shows that carbon dioxide-based cryotherapy may be equivalent to conventional argon-based cryotherapy in size of the ablation zone in a standard treatment time. The feasibility of the carbon dioxide device demonstrated in this study is an important step towards bringing accessible breast cancer treatment to women in low-resource settings.
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Affiliation(s)
- Yixin Hu
- Kubanda Cryotherapy, Inc., Baltimore, MD 21211, USA; (Y.H.); (N.G.); (K.O.)
| | - Naomi Gordon
- Kubanda Cryotherapy, Inc., Baltimore, MD 21211, USA; (Y.H.); (N.G.); (K.O.)
| | - Katherine Ogg
- Kubanda Cryotherapy, Inc., Baltimore, MD 21211, USA; (Y.H.); (N.G.); (K.O.)
| | - Dara L. Kraitchman
- Department of Radiology and Radiological Science, Johns Hopkins University, Baltimore, MD 21205, USA;
| | - Nicholas J. Durr
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD 21218, USA;
| | - Bailey Surtees
- Kubanda Cryotherapy, Inc., Baltimore, MD 21211, USA; (Y.H.); (N.G.); (K.O.)
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2
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Debreceni D, Janosi KF, Turcsan M, Toth D, Bocz B, Simor T, Kupo P. Feasibility and safety of cavotricuspid isthmus ablation using exclusive intracardiac echocardiography guidance: a proof-of-concept, observational trial. Front Cardiovasc Med 2023; 10:1244137. [PMID: 37900565 PMCID: PMC10601457 DOI: 10.3389/fcvm.2023.1244137] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 10/02/2023] [Indexed: 10/31/2023] Open
Abstract
Introduction Catheter ablation is the preferred treatment for typical atrial flutter (AFl), but it can be challenging due to anatomical abnormalities. The use of 3D electroanatomical mapping systems (EAMS) has reduced fluoroscopy exposure during AFl ablation. Intracardiac echocardiography (ICE) has also shown benefits in reducing radiation exposure during AFl ablation. However, there is a lack of evidence on the feasibility of ICE-guided, zero-fluoroscopy AFl ablation without the use of EAMS. Methods In this prospective study, we enrolled 80 patients with CTI-dependent AFl. The first 40 patients underwent standard fluoroscopy + ICE-guided ablation (Standard ICE group), while the other 40 patients underwent zero-fluoroscopy ablation using only ICE (Zero ICE group). Procedure outcomes, including acute success, procedure time, fluoroscopy time, radiation dose, and complications, were compared between the groups. Results The acute success rate was 100% in both groups. Out of the 40 cases, the zero-fluoroscopy strategy was successfully implemented in 39 cases (97.5%) in the Zero ICE group. There were no significant differences in procedure time [55.5 (46.5; 66.8) min vs. 51.5 (44.0; 65.5), p = 0.50] and puncture to first ablation time [18 (13.5; 23) min vs. 19 (15; 23.5) min, p = 0.50] between the groups. The Zero ICE group had significantly lower fluoroscopy time [57 (36.3; 90) sec vs. 0 (0; 0) sec, p < 0.001] and dose [3.17 (2.27; 5.63) mGy vs. 0 (0; 0) mGy, p < 0.001] compared to the Standard ICE group. Total ablation time was longer in the Standard ICE group [597 (447; 908) sec vs. 430 (260; 750), p = 0.02], but total ablation energy [22,458 (14,836; 31,116) Ws vs. 17,043 (10,533; 29,302) Ws, p = 0.10] did not differ significantly. First-pass bidirectional conduction block of the CTI and acute reconnection rates were similar between the groups. No complications or recurrences were observed during the follow-up period. Conclusion Our study suggests that zero-fluoroscopy CTI ablation guided solely by ICE for AFl is feasible and safe. Further investigation is warranted for broader validation.
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Affiliation(s)
| | | | | | | | | | | | - Peter Kupo
- Heart Institute, Medical School, University of Pecs, Pecs, Hungary
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3
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Turcsan M, Janosi KF, Debreceni D, Toth D, Bocz B, Simor T, Kupo P. Intracardiac Echocardiography Guidance Improves Procedural Outcomes in Patients Undergoing Cavotricuspidal Isthmus Ablation for Typical Atrial Flutter. J Clin Med 2023; 12:6277. [PMID: 37834921 PMCID: PMC10573340 DOI: 10.3390/jcm12196277] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 09/23/2023] [Accepted: 09/25/2023] [Indexed: 10/15/2023] Open
Abstract
Atrial flutter (AFL) represents a prevalent variant of supraventricular tachycardia, distinguished by a macro-reentrant pathway encompassing the cavotricuspid isthmus (CTI). Radiofrequency (RF) catheter ablation stands as the favored therapeutic modality for managing recurring CTI-dependent AFL. Intracardiac echocardiography (ICE) has been proposed as a method to reduce radiation exposure during CTI ablation. This study aims to comprehensively compare procedural parameters between ICE-guided CTI ablation and fluoroscopy-only procedures. A total of 370 consecutive patients were enrolled in our single-center retrospective study. In 151 patients, procedures were performed using fluoroscopy guidance only, while 219 patients underwent ICE-guided CTI ablation. ICE guidance significantly reduced fluoroscopy time (73 (36; 175) s vs. 900 (566; 1179) s; p < 0.001), fluoroscopy dose (2.45 (0.6; 5.1) mGy vs. 40.5 (25.7; 62.9) mGy; p < 0.001), and total procedure time (70 (52; 90) min vs. 87.5 (60; 102.5) min; p < 0.001). Total ablation time (657 (412; 981) s vs. 910 (616; 1367) s; p < 0.001) and the time from the first to last ablation (20 (11; 36) min vs. 40 (25; 55) min; p < 0.01) were also significantly shorter in the ICE-guided group. Acute success rate was 100% in both groups, and no major complications occurred in either group. ICE-guided CTI ablation in patients with AFL resulted in shorter procedure times, reduced fluoroscopy exposure, and decreased ablation times, compared to the standard fluoroscopy-only approach.
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Affiliation(s)
| | | | | | | | | | | | - Peter Kupo
- Heart Institute, Medical School, University of Pecs, Ifjusag utja 13, H-7624 Pecs, Hungary; (M.T.); (K.-F.J.); (D.D.); (D.T.); (B.B.); (T.S.)
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4
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Zeitler EP, Kim MH. Resource Use Following Atrial Fibrillation Ablation: Spending Resources to Save Resources. J Am Heart Assoc 2023; 12:e031411. [PMID: 37681513 PMCID: PMC10547283 DOI: 10.1161/jaha.123.031411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Affiliation(s)
- Emily P. Zeitler
- Dartmouth‐Hitchcock Medical Center and The Dartmouth InstituteLebanonNH
- The Geisel School of Medicine at DartmouthHanoverNH
| | - Michael H. Kim
- Creighton University School of Medicine and CHI HealthOmahaNE
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5
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Bocz B, Debreceni D, Janosi KF, Turcsan M, Simor T, Kupo P. Electroanatomical Mapping System-Guided vs. Intracardiac Echocardiography-Guided Slow Pathway Ablation: A Randomized, Single-Center Trial. J Clin Med 2023; 12:5577. [PMID: 37685645 PMCID: PMC10488800 DOI: 10.3390/jcm12175577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 08/22/2023] [Accepted: 08/25/2023] [Indexed: 09/10/2023] Open
Abstract
Radiofrequency (RF) catheter ablation is an effective treatment option for targeting the slow pathway (SP) in atrioventricular nodal reentry tachycardia (AVNRT). Previous data suggested that using intracardiac echocardiography (ICE) guidance could improve procedural outcomes when compared to using fluoroscopy alone. In this prospective study, we aimed to compare the effectiveness of an electroanatomical mapping system (EAMS)-guided approach with an ICE-guided approach for SP ablation. Eighty patients undergoing SP ablation for AVNRT were randomly assigned to either the ICE-guided or EAMS-guided group. If the procedural endpoint was not achieved after 8 RF applications; patients were allowed to crossover to the ICE-guided group. The ICE-guided approach reduced the total procedure time (61.0 (56.0; 66.8) min vs. 71.5 (61.0; 80.8) min, p < 0.01). However, the total fluoroscopy time was shorter (0 (0-0) s vs. 83.5 (58.5-133.25) s, p < 0.001) and the radiation dose was lower (0 (0-0) mGy vs. 3.3 (2.0-4.7) mGy, p < 0.001) with EAMS-guidance. The ICE-guided group had a lower number of RF applications (4 (3-5) vs. 5 (3.0-7.8), p = 0.03) and total ablation time (98.5 (66.8-186) s vs. 136.5 (100.5-215.8) s, p = 0.02). Nine out of 40 patients (22.5%) in the EAMS-guided group crossed over to the ICE-guided group, and they were successfully treated with similar RF applications in terms of number, time, and energy compared to the ICE-guided group. There were no recurrences during the follow-up period. In conclusion, the utilization of ICE guidance during SP ablation has demonstrated notable reductions in procedural time and RF delivery when compared to procedures guided by EAMS. In challenging cases, an early switch to ICE-guided ablation may be the optimal choice for achieving successful treatment.
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Affiliation(s)
| | | | | | | | | | - Peter Kupo
- Heart Institute, Medical School, University of Pecs, Ifjusag Utja 13, H-7624 Pécs, Hungary; (B.B.); (D.D.); (K.-F.J.); (M.T.); (T.S.)
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6
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Joseph C, Cooper J, Sikka R, Zagrodzky J, Turer RW, McDonald SA, Kulstad E, Daniels J. Improved hospital discharge and cost savings with esophageal cooling during left atrial ablation. J Med Econ 2023; 26:158-167. [PMID: 36537305 DOI: 10.1080/13696998.2022.2160596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Left atrial ablation to obtain pulmonary vein isolation (PVI) for the treatment of atrial fibrillation (AF) is a technologically intensive procedure utilizing innovative and continually improving technology. Changes in the technology utilized for PVI can in turn lead to changes in procedure costs. Because of the proximity of the esophagus to the posterior wall of the left atrium, various technologies have been utilized to protect against thermal injury during ablation. The impact on hospital costs during PVI ablation from utilization of different technologies for esophageal protection during ablation has not previously been evaluated. OBJECTIVE To compare the costs of active esophageal cooling to luminal esophageal temperature (LET) monitoring during left atrial ablation. METHODS We performed a time-driven activity-based costing (TDABC) analysis to determine costs for PVI procedures. Published data and literature review were utilized to determine differences in procedure time and same-day discharge rates using different esophageal protection technologies and to determine the cost impacts of same-day discharge versus overnight hospitalization after PVI procedures. The total costs were then compared between cases using active esophageal cooling to those using LET monitoring. RESULTS The effect of implementing active esophageal cooling was associated with up to a 24.7% reduction in mean total procedure time, and an 18% increase in same-day discharge rate. TDABC analysis identified a $681 reduction in procedure costs associated with the use of active esophageal cooling after including the cost of the esophageal cooling device. Factoring in the 18% increase in same-day discharge resulted in an increased cost savings of $2,135 per procedure. CONCLUSIONS The use of active esophageal cooling is associated with significant cost-savings when compared to traditional LET monitoring, even after accounting for the additional cost of the cooling device. These savings originate from a per-patient procedural time savings and a per-population improvement in same-day discharge rate.
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Affiliation(s)
| | - Julie Cooper
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Rishi Sikka
- Policy and Practice, Brown University School of Public Health, Providence, RI, USA
- Lifeforce Capital, San Francisco, CA, USA
| | - Jason Zagrodzky
- Texas Cardiac Arrhythmia Institute, St. David's South Austin Medical Center, Austin, TX, USA
| | - Robert W Turer
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Erik Kulstad
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - James Daniels
- University of Texas Southwestern Medical Center, Dallas, TX, USA
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7
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Ho RT. Does applying ICE make the pain better? J Cardiovasc Electrophysiol 2022; 33:2048-2049. [PMID: 35711035 DOI: 10.1111/jce.15601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 06/08/2022] [Accepted: 06/13/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Reginald T Ho
- Division of Cardiology, Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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8
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Randomized trial of intracardiac echocardiography-guided slow pathway ablation. J Interv Card Electrophysiol 2022; 63:709-714. [PMID: 35044581 DOI: 10.1007/s10840-022-01126-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 01/13/2022] [Indexed: 10/19/2022]
Abstract
PURPOSE Radiofrequency (RF) catheter ablation of the slow pathway (SP) in atrioventricular nodal reentry tachycardia (AVNRT) is highly effective; however, it may require prolonged fluoroscopy and RF time. We postulated that visualization of the SP region with intracardiac echocardiography (ICE) could decrease ablation time, minimize radiation exposure, and facilitate SP ablation compared to the standard, fluoroscopy-guided approach. METHODS In our study, we randomized 91 patients undergoing electrophysiologic study and SP ablation for AVNRT into 2 groups: fluoroscopy-only (n = 48) or ICE-guided (n = 43) group. Crossover to ICE-guidance was allowed after 8 unsuccessful RF applications. RESULTS Mapping plus ablation time (mean ± standard deviation: 18.8 ± 16.1 min vs 11.6 ± 15.0 min, p = 0.031), fluoroscopy time (median [interquartile range]: 4.9 [2.93-8.13] min vs. 1.8 [1.2-2.8] min, p < 0.001), and total ablation time (144 [104-196] s vs. 81 [60-159] s, p = 0.001) were significantly shorter in the ICE group. ICE-guidance was associated with reduced radiation exposure (13.2 [8.2-13.4] mGy vs. 3.7 [1.5-5.8] mGy, p < 0.001). The sum of delivered RF energy (3866 [2786-5656] Ws vs. 2283 [1694-4284] Ws, p = 0.002) and number of RF applications (8 [4.25-12.75] vs. 4 [2-7], p = 0.001) were also lower with ICE-guidance. Twelve (25%) patients crossed over to the ICE-guided group. All were treated successfully thereafter with similar number, time, and cumulative energy of RF applications compared to the ICE group. No recurrence occurred during the follow-up. CONCLUSIONS ICE-guidance during SP ablation significantly reduces mapping and ablation time, radiation exposure, and RF delivery in comparison to fluoroscopy-only procedures. Moreover, early switching to ICE-guided ablation seems to be an optimal choice in challenging cases.
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9
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Gallagher MM, Yi G, Gonna H, Leung LWM, Harding I, Evranos B, Bastiaenen R, Sharma R, Wright S, Norman M, Zuberi Z, Camm AJ. Multi-catheter cryotherapy compared with radiofrequency ablation in long-standing persistent atrial fibrillation: a randomized clinical trial. Europace 2021; 23:370-379. [PMID: 33188692 DOI: 10.1093/europace/euaa289] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 09/04/2020] [Indexed: 11/14/2022] Open
Abstract
AIMS Restoring sinus rhythm (SR) by ablation alone is an endpoint used in radiofrequency (RF) ablation for long-standing persistent atrial fibrillation (AF) but not with cryotherapy. The simultaneous use of two cryotherapy catheters can improve ablation efficiency; we compared this with RF ablation in chronic persistent AF aiming for termination to SR by ablation alone. METHODS AND RESULTS Consecutive patients undergoing their first ablation for persistent AF of >6 months duration were screened. A total of 100 participants were randomized 1:1 to multi-catheter cryotherapy or RF. For cryotherapy, a 28-mm Arctic Front Advance was used in tandem with focal cryoablation catheters. Open-irrigated, non-force sensing catheters were used in the RF group with a 3D mapping system. Pulmonary vein (PV) isolation and non-PV triggers were targeted. Participants were followed up at 6 and 12 months, then yearly. Acute PVI was achieved in all cases. More patients in the multi-catheter cryotherapy group were restored to SR by ablation alone, with a shorter procedure duration. Sinus rhythm continued to the last available follow-up in 16/49 patients (33%) in the multi-catheter at 3.0 ± 1.6 years post-ablation and in 12/50 patients (24%) in the RF group at 4.0 ± 1.2 years post-ablation. The yearly rate of arrhythmia recurrence was similar. CONCLUSION Multi-catheter cryotherapy can restore SR by ablation alone in more cases and more quickly than RF ablation. Long-term success is difficult to achieve by either methods and is similar with both.
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Affiliation(s)
- Mark M Gallagher
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Blackshaw Road, London SW17 0QT, UK
| | - Gang Yi
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Blackshaw Road, London SW17 0QT, UK
| | - Hanney Gonna
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Blackshaw Road, London SW17 0QT, UK
| | - Lisa W M Leung
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Blackshaw Road, London SW17 0QT, UK
| | - Idris Harding
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Blackshaw Road, London SW17 0QT, UK
| | - Banu Evranos
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Blackshaw Road, London SW17 0QT, UK
| | - Rachel Bastiaenen
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Blackshaw Road, London SW17 0QT, UK
| | - Rajan Sharma
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Blackshaw Road, London SW17 0QT, UK
| | - Sue Wright
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Blackshaw Road, London SW17 0QT, UK
| | - Mark Norman
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Blackshaw Road, London SW17 0QT, UK
| | - Zia Zuberi
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Blackshaw Road, London SW17 0QT, UK
| | - A John Camm
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Blackshaw Road, London SW17 0QT, UK
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10
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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] [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 Department, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Mohamed B Elshazly
- Research Department, Weill Cornell Medicine-Qatar, Doha, Qatar.,Joan and Sanford I. Weill Department of Medicine, Weill Cornell Medicine, New York, New York, USA.,Department of Cardiovascular Medicine, The Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Soha R Dargham
- Research Department, Weill Cornell Medicine-Qatar, Doha, Qatar.,Biostatistics, Epidemiology, and Biomathematics Research Core, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Eoin Donnellan
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Nidal Asaad
- Research Department, Weill Cornell Medicine-Qatar, Doha, Qatar.,Department of Cardiovascular Medicine, The Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Sajjad Hayat
- Research Department, Weill Cornell Medicine-Qatar, Doha, Qatar.,Department of Cardiovascular Medicine, The Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Mohamed Kanj
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Brian Baranowski
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Oussama Wazni
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Walid Saliba
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Charbel Abi Khalil
- Research Department, Weill Cornell Medicine-Qatar, Doha, Qatar.,Joan and Sanford I. Weill Department of Medicine, Weill Cornell Medicine, New York, New York, USA.,Department of Cardiovascular Medicine, The Heart Hospital, Hamad Medical Corporation, Doha, Qatar
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11
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Müller-Leisse J, Hillmann HAK, Veltmann C, Duncker D. ["Zero fluoro"-a chance for more women in electrophysiology]. Herzschrittmacherther Elektrophysiol 2021; 32:285-287. [PMID: 33944993 DOI: 10.1007/s00399-021-00767-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 04/14/2021] [Indexed: 11/25/2022]
Abstract
Many young women in cardiology are concerned about radiation exposure, and this issue contributes to the low number of female interventional cardiologists. The proportion of women in interventional electrophysiology is particularly low. However, radiation exposure during catheter ablation of arrhythmias can be minimized and even avoided completely using modern 3D mapping systems. The "zero fluoro" approach can improve patients' safety but also motivate more women to become interventional electrophysiologists.
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Affiliation(s)
- Johanna Müller-Leisse
- Hannover Herzrhythmus Centrum, Klinik für Kardiologie und Angiologie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland.
| | - Henrike Aenne Katrin Hillmann
- Hannover Herzrhythmus Centrum, Klinik für Kardiologie und Angiologie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
| | - Christian Veltmann
- Hannover Herzrhythmus Centrum, Klinik für Kardiologie und Angiologie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
| | - David Duncker
- Hannover Herzrhythmus Centrum, Klinik für Kardiologie und Angiologie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
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12
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Balan P, Eng MH. More energy, more costs. Catheter Cardiovasc Interv 2021; 97:1235. [PMID: 33974744 DOI: 10.1002/ccd.29720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 04/12/2021] [Indexed: 11/10/2022]
Affiliation(s)
- Prakash Balan
- Department of Medicine, Division of Cardiology, Banner University Medical Center, Phoenix, Arizona, USA
| | - Marvin H Eng
- Center for Structural Heart Disease, Henry Ford Hospital, Detroit, Michigan, USA
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13
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Friedman DJ, Holmes D, Curtis AB, Ellenbogen KA, Frankel DS, Knight BP, Russo AM, Matsouaka R, Turakhia MP, Lewis WR, Piccini JP. Procedure characteristics and outcomes of atrial fibrillation ablation procedures using cryoballoon versus radiofrequency ablation: A report from the GWTG-AFIB registry. J Cardiovasc Electrophysiol 2021; 32:248-259. [PMID: 33368764 DOI: 10.1111/jce.14858] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 11/24/2020] [Accepted: 12/10/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Cryoballoon ablation (CBA) is an alternative to radiofrequency ablation (RFA) for ablation of atrial fibrillation (AF) and real-world comparisons of this strategy are lacking. As such, we sought to compare patient and periprocedural characteristics and outcomes of CBA versus RFA in the Get With the Guidelines AFIB Registry. METHODS Categorical variables were compared via the χ2 test and continuous variables were compared via the Wilcoxon rank-sum test. Adjusted analyses were performed using overlap weighting of propensity scores. RESULTS A total of 5247 (1465 CBA, 3782 RFA) ablation procedures were reported from 33 sites. Those undergoing CBA more often had paroxysmal AF (60.0% vs. 48.8%) and no prior AF ablation (87.5% vs. 73.8%). CHA2 DS2 -VASc scores were similar. Among de novo ablations, most ablations involved intracardiac echocardiography and electroanatomic mapping, but both were less common with CBA (87.3% vs. 93.9%, p < .0001, and 87.7% vs. 94.6%, p < .0001, respectively). CBA was associated with shorter procedures (129 vs. 179 min, p < .0001), increased fluoroscopy use (19 vs. 11 min, p < .0001), and similar ablation times (27 vs. 35 min, p = .15). Nonpulmonary vein ablation was common with CBA: roof line 38.6%, floor line 20.4%, cavotricuspid isthmus 27.7%. RFA was associated with more total complications compared to CBA (5.4% vs. 2.3%, p < .0001), due to more volume overload and "other" events, although phrenic nerve injury was more common with CBA (0.9% vs 0.1%, p = .0001). In the adjusted model, any complication was less common among CBA cases (odds ratio, 0.45; confidence interval, 0.25-0.79, p = .0056). CONCLUSION CBA was associated with fewer complications, and shorter procedure times, and greater fluoroscopy times, compared to RFA. Nonpulmonary vein ablation and electroanatomic mapping system use was common with CBA.
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Affiliation(s)
- Daniel J Friedman
- Section of Cardiac Electrophysiology, Yale School of Medicine, New Haven, Connecticut, USA
| | | | - Anne B Curtis
- Department of Medicine, University at Buffalo, Buffalo, New York, USA
| | - Kenneth A Ellenbogen
- Division of Cardiology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - David S Frankel
- Electrophysiology Section, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Bradley P Knight
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Andrea M Russo
- Cooper Medical School of Rowan University, Camden, New Jersey, USA
| | | | - Mintu P Turakhia
- VA Palo Alto Health Care System, Palo Alto, California, USA.,Center for Digital Health, Stanford University School of Medicine, Stanford, California, USA
| | - William R Lewis
- MetroHealth System Campus, Case Western Reserve University, Cleveland, Ohio, USA
| | - Jonathan P Piccini
- Duke Clinical Research Institute, Durham, North Carolina, USA.,Electrophysiology Section, Duke University Hospital, Durham, North Carolina, USA
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14
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From electrophysiological exploration to management of heart arrhythmias: Economic analysis of practices in a high-volume French hospital over two different time periods. ANNALES PHARMACEUTIQUES FRANÇAISES 2020; 79:255-265. [PMID: 33152321 DOI: 10.1016/j.pharma.2020.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 10/09/2020] [Accepted: 10/13/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Medical devices (MD) used to treat arrhythmias range from electrophysiological exploration catheters to intracardiac ablation catheters, and they are continuously undergoing optimization. The inclusion of innovative MD in Diagnosis Related Groups (DRG) of the French healthcare economic system can lead to financial imbalance for health institutions. The objective of this study was to compare cost-revenue analyses for interventional heart rhythm management in a high-volume French hospital between two time periods. METHODS For 3 months in 2014 and 3 months in 2017, all of the patients admitted to the interventional rhythmic unit with arrhythmia were included retrospectively in this monocenter study. All arrhythmias were considered. The primary clinical endpoint was the difference between the expenses and incomes, calculated for each patient. The secondary endpoint was the breakdown of costs. RESULTS 217 patients were included. In 2014 period, the analysis revealed a deficit of 409±1717 euros per patient and an overall deficit for the hospital of 44,635 euros. In 2017 period, the same evaluation indicated a deficit of 446±1316 euros per patient and an overall deficit for the hospital of 48,210 euros. The cost of MD accounts for a significant share of total expenses. CONCLUSION The profitability for the cardiac rhythm activity at our facility was optimized between 2014 and 2017. The reliance on ambulatory care increased. However, the reduction in the expenses incurred did not increase the profitability for the facility. It was offset by a decrease in DRG tariffs. A flowchart-type structure based on these practices analyses for rhythmic disorder treatments was developed.
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15
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Mascia G, Giaccardi M. A New Era in Zero X-ray Ablation. Arrhythm Electrophysiol Rev 2020; 9:121-127. [PMID: 33240507 PMCID: PMC7675142 DOI: 10.15420/aer.2020.02] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Accepted: 07/03/2020] [Indexed: 11/28/2022] Open
Abstract
In this article, the authors focus on the importance of the zero X-ray ablation approach in electrophysiology. Radiation exposure related to conventional transcatheter ablation carries small but non-negligible stochastic and deterministic effects on health. Non-fluoroscopic mapping systems can significantly reduce, or even completely avoid, radiological exposure. The zero X-ray approach determines potential clinical benefits in terms of reduction of ionising radiation exposure, as well as safe technical advantages. The use of this method can result in similar outcomes when compared to the conventional fluoroscopic technique. These results are achieved without altering the duration, or compromising the effectiveness and safety, of the procedure. The zero X-ray ablation approach is a feasible and safe alternative to fluoroscopy, which is often only used in selected cases for troubleshooting. The non-fluoroscopic approach is considered a milestone for cancer prevention in ablation procedures.
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Affiliation(s)
- Giuseppe Mascia
- Department of Internal Medicine, IRCCS Ospedale Policlinico San Martino, University of Genoa, Genoa, Italy
| | - Marzia Giaccardi
- Department of Internal Medicine, Azienda USL Toscana Centro, Florence, Italy
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16
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Salam T, Wilson L, Bohannan S, Morin M. Safety and Effectiveness of a Novel Fluoroless Transseptal Puncture Technique for Lead-free Catheter Ablation: A Case Series. J Innov Card Rhythm Manag 2020; 11:4079-4085. [PMID: 32368383 PMCID: PMC7192152 DOI: 10.19102/icrm.2020.110405] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 10/28/2019] [Indexed: 01/07/2023] Open
Abstract
Increasing awareness of the health risks associated with the exposure of patients and staff in the catheterization laboratory to radiation has encouraged the pursuit of efforts to reduce the use of fluoroscopy during catheter ablation procedures. Although nonfluoroscopic guidance of ablation catheters has been previously described, transseptal access is still perceived as the last remaining barrier to completely fluoroless ablations. This study examined the safety and effectiveness of transseptal puncture and radiofrequency (RF) catheter ablation using a completely fluoroless approach. Three hundred eighty-two consecutive cases that had undergone completely nonfluoroscopic RF catheter ablation were evaluated. Ablation procedures were performed for atrial fibrillation, atrial flutter, atrioventricular reentry tachycardia, and pulmonary vein complex/ventricular tachycardia. Transseptal puncture and RF ablation were conducted under three-dimensional electroanatomic mapping and intracardiac echocardiography image guidance. Fluoroless transseptal puncture and catheter ablation were completed successfully in all cases, with no intraoperative complications. One patient required minimal use of fluoroscopy to visualize sheath advancement through an existing inferior vena cava filter. Procedural time was approximately 2.2 hours from transvenous access until case conclusion; transseptal access was obtained within 28 minutes of procedure initiation. Arrhythmia was found to recur in 27% of cases on average three months after the procedure. We demonstrate the safety and effectiveness of a completely fluoroless transseptal puncture and RF ablation technique that eliminates radiation exposure and enables complex electrophysiology procedures to be performed in a lead-free environment.
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Affiliation(s)
- Tariq Salam
- Pulse Heart Institute, MultiCare Health System, Tacoma, WA, USA
| | - Lane Wilson
- Pulse Heart Institute, MultiCare Health System, Tacoma, WA, USA
| | - Sara Bohannan
- Pulse Heart Institute, MultiCare Health System, Tacoma, WA, USA
| | - Michael Morin
- Pulse Heart Institute, MultiCare Health System, Tacoma, WA, USA
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17
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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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18
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Gautam S. Primum Non Nocere. JACC Clin Electrophysiol 2020; 6:125-126. [DOI: 10.1016/j.jacep.2019.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 07/18/2019] [Indexed: 10/25/2022]
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19
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Murray MI, Bonet MJ, Naci H, Zeiher AM. A Cost-Utility Analysis of Cryoballoon Ablation versus Radiofrequency Ablation for Paroxysmal Atrial Fibrillation. J Atr Fibrillation 2019; 11:2069. [PMID: 31139282 DOI: 10.4022/jafib.2069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 08/19/2017] [Accepted: 10/14/2018] [Indexed: 11/10/2022]
Abstract
Introduction The objective of this study was to evaluate the cost-effectiveness of the treatment with cryoballoon (CB) compared to the standard treatment with traditional irrigated radiofrequency (RF) ablation for pulmonary vein isolation in patients with paroxysmal atrial fibrillation (pAF) refractory to antiarrhythmic drug therapy. Methods A decision tree model was developed to graphically depict the probabilities, utilities and costs of CB compared to RF therapy. Data from a conducted systematic literature review and meta-analysis of only RCTs were used to evaluate clinical outcomes of CB and RF treatments, including success rates after one year, complications and recurrence of atrial fibrillation. Results The cost-utility analysis estimated that, CB therapy had £1,747 higher cost, and 0.0114 more quality-adjusted life years (QALYs) compared to standard RF treatment over a one-year time horizon. The incremental cost per QALY of CB ablation compared to RF ablation was estimated to be £152,836/QALY. Conclusions Based on current evidence, CB ablation for pulmonary vein isolation in patients with pAF is costeffective compared to RF if decision makers are willing to pay £152,836 or higher for a QALY.
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Affiliation(s)
- Marie-Isabel Murray
- Department of Cardiology, University Hospital Frankfurt, Frankfurt am Main, Germany.,Department of Health Policy, London School of Economics and Political Science, London, UK.,Department of Health Policy, London School of Economics and Political Science, London, UK
| | | | - Huseyin Naci
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Andreas M Zeiher
- Department of Cardiology, University Hospital Frankfurt, Frankfurt am Main, Germany
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20
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Pollak SJ, Goldstein L, Daskiran M, Kalsekar I, Khanna R. Economic impact of atrial fibrillation ablation with radiofrequency contact force catheter versus cryoballoon catheter. J Comp Eff Res 2018; 8:251-264. [PMID: 30572711 DOI: 10.2217/cer-2018-0112] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
AIM To compare health utilization among atrial fibrillation (AF) patients undergoing ablation with a contact force-sensing (CF) catheter versus a cryoballoon (CB) catheter. METHODS AF patients who underwent ablation using the CF catheter (THERMOCOOL SMARTTOUCH® catheter) or CB catheter (Arctic Front™/Arctic Front Advance™ catheter) were identified from the Premier Healthcare database. Propensity score analyses were used to evaluate cost, length of stay and readmissions. RESULTS The CF catheter (n = 1409) was associated with significantly lower total (∼7%) and supply (∼13%) costs and a significantly lower likelihood of 4-12 month all-cause and CV-related readmission compared with the CB catheter (n = 2306). CONCLUSION Differential health utilization outcomes are associated with the CF catheter versus the CB catheter in AF ablation.
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Affiliation(s)
- Scott J Pollak
- Florida Hospital Cardiovascular Institute, Orlando, FL, USA
| | - Laura Goldstein
- Johnson & Johnson Medical Devices, Franchise Health Economics & Market Access, Irvine, CA, USA
| | | | - Iftekhar Kalsekar
- Medical Device Epidemiology, Johnson & Johnson, New Brunswick, NJ, USA
| | - Rahul Khanna
- Medical Device Epidemiology, Johnson & Johnson, New Brunswick, NJ, USA
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21
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Bansal M, Molian VA, Maldonado JR, Aldoss O, Ochoa LA, Law IH. Cost analysis of combining congenital cardiac catheterization and electrophysiology procedures in an outpatient setting. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2018; 41:1428-1434. [PMID: 30151836 DOI: 10.1111/pace.13477] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 08/10/2018] [Accepted: 08/14/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patients with congenital heart disease require multiple procedures over their lifetime. These procedures increase cost and time commitment. Previous studies in the field of medicine have shown that combining procedures is an effective method to reduce cost and time. There has been no such study to evaluate the cost and efficiency of combining pediatric cardiac procedures. OBJECTIVE The objective of this study was to compare the cost and time commitment of combined cardiac catheterization (cath) and electrophysiology (EP) outpatient procedures against separate cath and EP procedure. METHODS Outpatient combination procedures performed in the pediatric cardiac cath lab from 2013 to 2016 were matched to a control population of two or three similar single outpatient procedures from 2009 to 2016 for patients of similar age and cardiac anatomy. Procedure duration, recovery duration, length of stay, equipment charges, physician charges, all other hospital charges, and total admission charges were analyzed. The two groups were compared using an unpaired t-test. RESULTS A total of 92 subjects, 32 study subjects and 60 control subjects, were included in this study. Study group procedures had a significantly shorter recovery duration (P = 0.04) and length of stay (P = 0.01). Study group procedure duration trended shorter on average but statistically insignificant (P = 0.20). The total median savings for patients undergoing combined procedures in the study group was $13,181 (interquartile range $423.8-$26710). CONCLUSIONS Combining cath and EP outpatient procedures reduces the time commitment and provides some economic advantage.
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Affiliation(s)
- Manish Bansal
- Division of Pediatric Cardiology, University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA
| | - Vaelan A Molian
- Division of Pediatric Cardiology, University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA
| | - Jennifer R Maldonado
- Division of Pediatric Cardiology, University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA
| | - Osamah Aldoss
- Division of Pediatric Cardiology, University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA
| | - Luis A Ochoa
- Division of Pediatric Cardiology, University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA
| | - Ian H Law
- Division of Pediatric Cardiology, University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA
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22
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Perino AC, Fan J, Schmitt SK, Kaiser DW, Heidenreich PA, Narayan SM, Wang PJ, Chang AY, Turakhia MP. Patient and facility variation in costs of catheter ablation for atrial fibrillation. J Cardiovasc Electrophysiol 2018; 29:1081-1088. [PMID: 29864193 PMCID: PMC6469652 DOI: 10.1111/jce.13655] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 04/21/2018] [Accepted: 05/14/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cost-effectiveness or value of cardiovascular therapies may be undermined by unwarranted cost variation, particularly for heterogeneous procedures such as catheter ablation for atrial fibrillation (AF). We sought to characterize cost variation of AF ablation in the US healthcare system and the relationship between cost and outcomes. METHODS AND RESULTS We performed a retrospective cohort study using data from the MarketScan® commercial claims and Medicare supplemental databases including patients who received an AF ablation from 2007 to 2011. We aggregated encounter cost, reflecting total payments received for the encounter, to the facility level to calculate median facility cost. We classified procedures as outpatient or inpatient and assessed for association between cost and 30-day and 1-year outcomes. The analysis cohort included 9,415 AF ablations (59±11 years; 28% female; 52% outpatient) occurring at 327 facilities, with large cost variation across facilities (median: $25,100; 25th percentile: $18,900, 75th percentile: $35,600, 95th percentile: $57,800). Among outpatient procedures, there was reduced healthcare utilization in higher cost quintiles with reductions in rehospitalization at 30-days (Quintile 1: 16.1%, Quintile 5: 8.8%, P < 0.001) and 1-year (Quintile 1: 34.8%, Quintile 5: 25.6%, P < 0.001), which remained significant in multivariate analysis. CONCLUSIONS Although median costs of AF ablation are below amounts used in prior cost-effectiveness studies that demonstrated good value, large facility variation in cost suggests opportunities for cost reduction. However, for outpatient encounters, association of cost to modestly improved outcomes suggests cost containment strategies could have variable effects.
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Affiliation(s)
- Alexander C Perino
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Jun Fan
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Susan K Schmitt
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Daniel W Kaiser
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Paul A Heidenreich
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Sanjiv M Narayan
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Paul J Wang
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Andrew Y Chang
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Mintu P Turakhia
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Center for Digital Health, Stanford University School of Medicine, Stanford, CA, USA
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23
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Calkins H, Hindricks G, Cappato R, Kim YH, Saad EB, Aguinaga L, Akar JG, Badhwar V, Brugada J, Camm J, Chen PS, Chen SA, Chung MK, Cosedis Nielsen J, Curtis AB, Davies DW, Day JD, d’Avila A, (Natasja) de Groot NMS, Di Biase L, Duytschaever M, Edgerton JR, Ellenbogen KA, Ellinor PT, Ernst S, Fenelon G, Gerstenfeld EP, Haines DE, Haissaguerre M, Helm RH, Hylek E, Jackman WM, Jalife J, Kalman JM, Kautzner J, Kottkamp H, Kuck KH, Kumagai K, Lee R, Lewalter T, Lindsay BD, Macle L, Mansour M, Marchlinski FE, Michaud GF, Nakagawa H, Natale A, Nattel S, Okumura K, Packer D, Pokushalov E, Reynolds MR, Sanders P, Scanavacca M, Schilling R, Tondo C, Tsao HM, Verma A, Wilber DJ, Yamane T. 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. Europace 2018; 20:e1-e160. [PMID: 29016840 PMCID: PMC5834122 DOI: 10.1093/europace/eux274] [Citation(s) in RCA: 681] [Impact Index Per Article: 113.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- Hugh Calkins
- From the Johns Hopkins Medical Institutions, Baltimore, MD
| | | | - Riccardo Cappato
- Humanitas Research Hospital, Arrhythmias and Electrophysiology Research Center, Milan, Italy (Dr. Cappato is now with the Department of Biomedical Sciences, Humanitas University, Milan, Italy, and IRCCS, Humanitas Clinical and Research Center, Milan, Italy)
| | | | - Eduardo B Saad
- Hospital Pro-Cardiaco and Hospital Samaritano, Botafogo, Rio de Janeiro, Brazil
| | | | | | - Vinay Badhwar
- West Virginia University School of Medicine, Morgantown, WV
| | - Josep Brugada
- Cardiovascular Institute, Hospital Clínic, University of Barcelona, Catalonia, Spain
| | - John Camm
- St. George's University of London, London, United Kingdom
| | | | | | | | | | | | - D Wyn Davies
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - John D Day
- Intermountain Medical Center Heart Institute, Salt Lake City, UT
| | | | | | - Luigi Di Biase
- Albert Einstein College of Medicine, Montefiore-Einstein Center for Heart & Vascular Care, Bronx, NY
| | | | | | | | | | - Sabine Ernst
- Royal Brompton and Harefield NHS Foundation Trust, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Guilherme Fenelon
- Albert Einstein Jewish Hospital, Federal University of São Paulo, São Paulo, Brazil
| | | | | | | | | | - Elaine Hylek
- Boston University School of Medicine, Boston, MA
| | - Warren M Jackman
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Jose Jalife
- University of Michigan, Ann Arbor, MI, the National Center for Cardiovascular Research Carlos III (CNIC) and CIBERCV, Madrid, Spain
| | - Jonathan M Kalman
- Royal Melbourne Hospital and University of Melbourne, Melbourne, Australia
| | - Josef Kautzner
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Hans Kottkamp
- Hirslanden Hospital, Department of Electrophysiology, Zurich, Switzerland
| | | | | | - Richard Lee
- Saint Louis University Medical School, St. Louis, MO
| | - Thorsten Lewalter
- Department of Cardiology and Intensive Care, Hospital Munich-Thalkirchen, Munich, Germany
| | | | - Laurent Macle
- Montreal Heart Institute, Department of Medicine, Université de Montréal, Montréal, Canada
| | | | - Francis E Marchlinski
- Hospital of the University of Pennsylvania, University of Pennsylvania School of Medicine, Philadelphia, PA
| | | | - Hiroshi Nakagawa
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX
| | - Stanley Nattel
- Montreal Heart Institute and Université de Montréal, Montreal, Canada, McGill University, Montreal, Canada, and University Duisburg-Essen, Essen, Germany
| | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | | | - Evgeny Pokushalov
- State Research Institute of Circulation Pathology, Novosibirsk, Russia
| | | | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | | | - Claudio Tondo
- Cardiac Arrhythmia Research Center, Centro Cardiologico Monzino, IRCCS, Department of Cardiovascular Sciences, University of Milan, Milan, Italy
| | | | - Atul Verma
- Southlake Regional Health Centre, University of Toronto, Toronto, Canada
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Alkhouli M, Rihal CS, Holmes DR. Transseptal Techniques for Emerging Structural Heart Interventions. JACC Cardiovasc Interv 2017; 9:2465-2480. [PMID: 28007198 DOI: 10.1016/j.jcin.2016.10.035] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 09/25/2016] [Accepted: 10/06/2016] [Indexed: 12/18/2022]
Abstract
The development of new transseptal transcatheter interventions for patients with structural heart disease is fueling increasing interest in transseptal puncture techniques. The authors review contemporary transseptal puncture indications and techniques and provide a step-by-step approach to challenging transseptal access and procedural complications.
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Affiliation(s)
- Mohamad Alkhouli
- Divisions of Cardiovascular Diseases and Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Charanjit S Rihal
- Divisions of Cardiovascular Diseases and Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - David R Holmes
- Divisions of Cardiovascular Diseases and Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota.
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WITHDRAWN: 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. J Arrhythm 2017. [DOI: 10.1016/j.joa.2017.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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26
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Pambrun T, Combes S, Sousa P, Bloa ML, El Bouazzaoui R, Grand-Larrieu D, Thompson N, Martin R, Combes N, Boveda S, Haïssaguerre M, Albenque JP. Contact-force guided single-catheter approach for pulmonary vein isolation: Feasibility, outcomes, and cost-effectiveness. Heart Rhythm 2017; 14:331-338. [DOI: 10.1016/j.hrthm.2016.12.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Indexed: 12/31/2022]
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27
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Winkle RA, Mead RH. Thought leaders saving money: One catheter at a time. Heart Rhythm 2016; 14:339-340. [PMID: 28007542 DOI: 10.1016/j.hrthm.2016.12.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Indexed: 11/24/2022]
Affiliation(s)
- Roger A Winkle
- Silicon Valley Cardiology, Palo Alto Medical Foundation, Sutter Health, E. Palo Alto, California.
| | - R Hardwin Mead
- Silicon Valley Cardiology, Palo Alto Medical Foundation, Sutter Health, E. Palo Alto, California
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Plehn G, Butz T, Maagh P, Oernek A, Meissner A, Plehn N. Is it time to rebalance the case mix? A portfolio analysis of direct catheterization laboratory costs over a 5-year period. Eur J Med Res 2016; 21:44. [PMID: 27809933 PMCID: PMC5094137 DOI: 10.1186/s40001-016-0238-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Accepted: 10/19/2016] [Indexed: 11/15/2022] Open
Abstract
Background Cardiac catheterization laboratories (CLL) have continued to function as profit centers for hospitals. Due to a high percentage of material and labor costs, they are natural targets for process improvement. Our study applied a contribution margin (CBM) concept to evaluate costs and cost dynamics over a 5-year period. Methods We retrospectively analyzed all procedures performed at a tertiary heart center between 2007 and 2011. Total variable costs, including labor time, material, and maintenance-expenses, were allocated at a global as well as a procedural level. CBM and CBM ratios were calculated by integration of individual DRG revenues. Results Annual case volume increased from 1288 to 1545. In parallel, overall profitability improved as indicated by a 2% increase in CBM ratio and a higher CBM generated per hour of CLL working time (4325 vs. 5892 €, p < 0.001). Coronary angiography generated higher average CBMs per hour than coronary or electrophysiological interventions (5831 vs. 3458 vs. 1495 €; p < 0.001). The latter are characterized by relatively high per case material expenditures. On a procedural level, DRG-specific trends as a steady improvement of examination time or an increase in material costs were detectable. Conclusions The CBM concept allows a comprehensive analysis of CLL costs and cost dynamics. From a health service providers view, its range of application includes global profitability analysis, portfolio evaluation, and a detailed cost analysis of specific service lines. From a healthcare payers perspective, it may help to monitor hospital activities and to provide a solid data basis in cases where inappropriate developments are suspected. The calculation principle is simple which may increase user acceptance and thus the motivation of team members. Electronic supplementary material The online version of this article (doi:10.1186/s40001-016-0238-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Gunnar Plehn
- Department of Cardiology, Johanniter-Hospital Duisburg Rheinhausen, Germany, Kreuzacker 1-7, 47228, Duisburg, Germany. .,Ruhr-University of Bochum, Universitätsstrasse 150, 44801, Bochum, Germany.
| | - Thomas Butz
- Department of Cardiology, Catholic Hospital Oberhausen, Wilhelmstrasse 34, 46145, Oberhausen, Germany
| | - Petra Maagh
- Ruhr-University of Bochum, Universitätsstrasse 150, 44801, Bochum, Germany.,Department of Cardiology, Cologne-Merheim-Hospital, Ostmerheimer Strasse 200, 51109, Cologne, Germany
| | - Ahmet Oernek
- Department of Radiology, University Hospital Bergmannsheil Bochum, Bürkle de la Camp-Platz 1, 44789, Bochum, Germany
| | - Axel Meissner
- Ruhr-University of Bochum, Universitätsstrasse 150, 44801, Bochum, Germany.,Department of Cardiology, Cologne-Merheim-Hospital, Ostmerheimer Strasse 200, 51109, Cologne, Germany
| | - Natalie Plehn
- Schumpeter School of Business and Economics, University of Wuppertal, Gaussstrasse 20, 42119, Wuppertal, Germany
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Mujović N, Marinković M, Marković N, Kocijančić A, Kovačević V, Simić D, Ristić A, Stanković G, Miličić B, Putnik S, Vujisić-Tešić B, Potpara TS. Management and Outcome of Periprocedural Cardiac Perforation and Tamponade with Radiofrequency Catheter Ablation of Cardiac Arrhythmias: A Single Medium-Volume Center Experience. Adv Ther 2016; 33:1782-1796. [PMID: 27554091 PMCID: PMC5055551 DOI: 10.1007/s12325-016-0402-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Indexed: 11/04/2022]
Abstract
Introduction Cardiac tamponade (CT) is a life-threatening complication of radiofrequency ablation (RFA). The course and outcome of CT in low-to-medium volume electrophysiology centers are underreported. Methods We analyzed the incidence, management and outcomes of CT in 1500 consecutive RFAs performed in our center during 2011–2016. Results Of 1500 RFAs performed in 1352 patients (age 55 years, interquartile range: 41–63), 569 were left-sided procedures (n = 406 with transseptal access). Conventional RFA or irrigated RFA was performed in 40.9% and 59.1% of procedures, respectively. Ablation was performed mostly for atrioventricular nodal reentrant tachycardia (25.4%), atrial fibrillation (AF; 18.5%), atrial flutter (18.4%), accessory pathway (16.5%) or idiopathic ventricular arrhythmia (VA; 12.3%), and rarely for structural VA (2.1%). CT occurred in 12 procedures (0.8%): 10 AF ablations, 1 idiopathic VA and 1 typical atrial flutter ablation. Factors significantly associated with CT were older age, pre-procedural oral anticoagulation, left-sided procedures, transseptal access, AF ablation, irrigated RFA and longer fluoroscopy time (on univariate analysis), and AF ablation (on multivariable analysis). The perforation site was located in the left atrium (n = 7), right atrium (n = 3), or in the left ventricle or coronary sinus (n = 1 each). Upon pericardiocentesis, two patients underwent urgent cardiac surgery because of continued bleeding. There was no fatal outcome. During the follow-up of 19 ± 14 months, eight patients were arrhythmia free. Conclusion Incidence of RFA-related CT in our medium-volume center was low and significantly associated with AF ablation. The outcome of CT was mostly favorable after pericardiocentesis, but readily accessible cardiothoracic surgery back-up should be mandatory in RFA centers.
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Kusumoto F. Introduction: health policy II. A new era of heath policy in electrophysiology and cardiology. J Interv Card Electrophysiol 2016; 47:1-3. [PMID: 27637786 DOI: 10.1007/s10840-016-0182-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 08/26/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Fred Kusumoto
- Heart Rhythm Service, Department of Cardiovascular Disease, Mayo Clinic, Jacksonville, FL, 32224, USA. .,Electrophysiology and Pacing Service, Division of Cardiovascular Disease, Mayo Clinic, 4500 San Pablo Ave, Jacksonville, FL, 32224, USA.
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Gonzalez J, Levinstein M, Brugada P. [Cryoablation: Clinical applications in cardiac electrophysiology from their biophysical bases]. ARCHIVOS DE CARDIOLOGIA DE MEXICO 2015; 86:41-50. [PMID: 26556222 DOI: 10.1016/j.acmx.2015.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 09/14/2015] [Accepted: 09/29/2015] [Indexed: 10/22/2022] Open
Abstract
Cryoablation is an energy alternative to radiofrequency for ablation of various arrhythmias, where its unique biophysical properties offer a greater safety profile. Since its first use for the surgical treatment of different arrhythmias until its conceptualization in the current technical transcatheter, cryoablation has proven not to be only a safe source of energy, but also an effective source in the long-term. While the radiofrequency has been the energy most used for isolation of pulmonary veins in atrial fibrillation ablation, technological advances in cryoballon have managed to simplify the procedure without sacrificing its effectiveness. Cryoablation has been widely used for arrhythmias located in high-risk locations, such as the ablation of the atrioventricular nodal reentrant tachycardia and septal accessory pathways, due to its theoretical null risk of complete AV block. This review intends to give the clinical applications of the cryothermy through a thorough understanding of their biophysical basis.
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Affiliation(s)
- Jorge Gonzalez
- Centro Especializado en Terapia Endovascular, Jardines Hospital de Especialidad, Guadalajara, Jalisco, México.
| | | | - Pedro Brugada
- Heart Rhythm Management Centre, UZ Brussel-VUB, Bruselas, Bélgica
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Kummer BR, Bhave PD, Merkler AE, Gialdini G, Okin PM, Kamel H. Demographic Differences in Catheter Ablation After Hospital Presentation With Symptomatic Atrial Fibrillation. J Am Heart Assoc 2015; 4:e002097. [PMID: 26396201 PMCID: PMC4599497 DOI: 10.1161/jaha.115.002097] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 07/31/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND Catheter ablation is increasingly used for rhythm control in symptomatic atrial fibrillation (AF), but the demographic characteristics of patients undergoing this procedure are unclear. METHODS AND RESULTS We used data on all admissions at nonfederal acute care hospitals in California, Florida, and New York to identify patients discharged with a primary diagnosis of AF between 2006 and 2011. Our primary outcome was readmission for catheter ablation of AF, identified using validated International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes. Cox regression models were used to assess relationships between demographic characteristics and catheter ablation, adjusting for Elixhauser comorbidities. We identified 397 612 eligible patients. Of these, 16 717 (4.20%, 95% CI 0.41 to 0.43) underwent ablation. These patients were significantly younger, more often male, more often white, and more often privately insured, with higher household incomes and lower rates of medical comorbidity. In Cox regression models, the likelihood of ablation was lower in women than men (hazard ratio [HR] 0.83; 95% CI 0.80 to 0.86) despite higher rates of AF-related rehospitalization (HR 1.23; 95% CI 1.21 to 1.24). Compared to whites, the likelihood of ablation was lower in Hispanics (HR 0.60; 95% CI 0.56 to 0.64) and blacks (HR 0.68; 95% CI 0.64 to 0.73), even though blacks had only a slightly lower likelihood of AF-related rehospitalization (HR 0.97; 95% CI 0.94 to 0.99) and a higher likelihood of all-cause hospitalization (HR 1.38; 95% CI 1.37 to 1.39). Essentially the same pattern existed in Hispanics. CONCLUSIONS We found differences in use of catheter ablation for symptomatic AF according to sex and race despite adjustment for available data on demographic characteristics and medical comorbidities.
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Affiliation(s)
- Benjamin R Kummer
- Department of Neurology, Neurological Institute of New York, Columbia University College of Physicians and SurgeonsNew York, NY
| | - Prashant D Bhave
- Division of Cardiology, University of Iowa Carver College of MedicineIowa City, IA
| | | | - Gino Gialdini
- Feil Family Brain and Mind Research Institute, Weill Cornell Medical CollegeNew York, NY
| | - Peter M Okin
- Division of Cardiology, Weill Cornell Medical CollegeNew York, NY
| | - Hooman Kamel
- Department of Neurology, Weill Cornell Medical CollegeNew York, NY
- Feil Family Brain and Mind Research Institute, Weill Cornell Medical CollegeNew York, NY
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Sundaram S, Mam C, Choe W, Aleong R, Reddy K, Jared Bunch T. Atrial fibrillation ablation performed in the developing world: A description of the first atrial fibrillation ablation performed in Cambodia. HeartRhythm Case Rep 2015; 1:360-362. [PMID: 28491584 PMCID: PMC5419669 DOI: 10.1016/j.hrcr.2015.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2022] Open
Affiliation(s)
- Sri Sundaram
- South Denver Cardiology Associates, Littleton, Colorado
| | | | - William Choe
- South Denver Cardiology Associates, Littleton, Colorado
| | - Ryan Aleong
- Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado
| | | | - T Jared Bunch
- Division of Cardiac Electrophysiology, Intermountain Health, Murray, Utah
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Chang AY, Kaiser D, Ullal A, Perino AC, Heidenreich PA, Turakhia MP. Evaluating the Cost-effectiveness of Catheter Ablation of Atrial Fibrillation. Arrhythm Electrophysiol Rev 2014; 3:177-83. [PMID: 26835088 DOI: 10.15420/aer.2014.3.3.177] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Accepted: 11/22/2014] [Indexed: 01/01/2023] Open
Abstract
Atrial fibrillation (AF) is one of the most common cardiac conditions treated in primary care and specialty cardiology settings, and is associated with considerable morbidity, mortality and cost. Catheter ablation, typically by electrically isolating the pulmonary veins and surrounding tissue, is more effective at maintaining sinus rhythm than conventional antiarrhythmic drug therapy and is now recommended as first-line therapy. From a value standpoint, the cost-effectiveness of ablation must incorporate the upfront procedural costs and risks with the benefits of longer term improvements in quality of life (QOL) and healthcare utilisation. Here, we present a primer on cost-effectiveness analysis (CEA), review the data on cost-effectiveness of AF ablation and outline key areas for further investigation.
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Affiliation(s)
- Andrew Y Chang
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Daniel Kaiser
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Aditya Ullal
- Veterans Affairs Palo Alto Health Care System, California, US
| | - Alexander C Perino
- Department of Medicine, Stanford University School of Medicine, Stanford, California; Veterans Affairs Palo Alto Health Care System, California, US
| | - Paul A Heidenreich
- Department of Medicine, Stanford University School of Medicine, Stanford, California; Veterans Affairs Palo Alto Health Care System, California, US
| | - Mintu P Turakhia
- Department of Medicine, Stanford University School of Medicine, Stanford, California; Veterans Affairs Palo Alto Health Care System, California, US
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Jones MA, Webster D, Wong KCK, Hayes C, Qureshi N, Rajappan K, Bashir Y, Betts TR. The benefit of tissue contact monitoring with an electrical coupling index during ablation of typical atrial flutter--a prospective randomised control trial. J Interv Card Electrophysiol 2014; 41:237-44. [PMID: 25234603 DOI: 10.1007/s10840-014-9943-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Accepted: 07/30/2014] [Indexed: 11/26/2022]
Abstract
INTRODUCTION We sought to investigate the use of tissue contact monitoring by means of the electrical coupling index (ECI) in a prospective randomised control trial of patients undergoing cavotricuspid isthmus (CTI) ablation for atrial flutter. METHODS Patients with ECG-documented typical flutter undergoing their first CTI ablation were randomised to ECI™-guided or non-ECI™-guided ablation. An irrigated-tip ablation catheter was used in all cases. Consecutive 50-W, 60-s radiofrequency lesions were applied to the CTI, from the tricuspid valve to inferior vena cava, with no catheter movement permitted during radiofrequency (RF) delivery. The ablation endpoint was durable CTI block at 20 min post-ablation. Patients underwent routine clinic follow-up post-operatively. RESULTS A total of 101 patients (79 male), mean age 66 (+/-11), 50 ECI-guided and 51 control cases were enrolled in the study. CTI block was achieved in all. There were no acute complications. All patients were alive at follow-up. CTI block was achieved in a single pass in 36 ECI-guided and 30 control cases (p = 0.16), and at 20 min post-ablation, re-conduction was seen in 5 and 12 cases, respectively (p = 0.07). There was no significant difference in total procedure time (62.7 ± 33 vs. 62.3 ± 33 min, p = 0.92), RF requirement (580 ± 312 vs. 574 ± 287 s, p = 0.11) or fluoroscopy time (718 ± 577 vs. 721 ± 583 s, p = 0.78). After 6 ± 4 months, recurrence of flutter had occurred in 1 (2 %) ECI vs. 8 (16 %) control cases (OR 0.13, 95 % CI 0.01-1.08, p = 0.06). CONCLUSIONS ECI-guided CTI ablation demonstrated a non-statistically significant reduction in late recurrence of atrial flutter, at no cost to procedural time, radiation exposure or RF requirement.
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Affiliation(s)
- Michael A Jones
- Department of Cardiology, Oxford University Hospitals NHS Trust, Oxford, OX3 9DU, United Kingdom,
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Pavlovic N, Knecht S, Reichlin T, Kühne M, Sticherling C. Cryoballoon ablation for atrial fibrillation. Interv Cardiol 2014. [DOI: 10.2217/ica.14.40] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Pokorney SD, Hammill BG, Qualls LG, Steinberg BA, Curtis LH, Piccini JP. Cost analysis of periprocedural imaging in patients undergoing catheter ablation for atrial fibrillation. Am J Cardiol 2014; 114:266-71. [PMID: 24952929 PMCID: PMC4090097 DOI: 10.1016/j.amjcard.2014.04.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 04/14/2014] [Accepted: 04/14/2014] [Indexed: 10/25/2022]
Abstract
Cardiovascular imaging is an important part of procedural planning and safety for catheter ablation of atrial fibrillation (AF). However, the costs of imaging surrounding catheter ablation of AF have not been described. Medicare fee-for-service data were used to evaluate Medicare expenditures before, during, and after catheter ablation for AF from July 2007 to December 2009. Among 11,525 patients who underwent catheter ablation for AF, the mean overall expenditure on the day of the procedure was $14,455 (SD $7,441). The mean imaging expenditure in the periprocedural period, which included the 30 days before the catheter ablation and the day of the ablation itself, was $884 (SD $455). Periprocedural imaging expenditures varied by the imaging strategy used, ranging from a mean of $557 (SD $269) for patients with electroanatomic mapping only to $1,234 (SD $461) for patients with electroanatomic mapping, transesophageal echocardiogram, and computed tomography or magnetic resonance imaging. Mean patient-level imaging expenditures varied by provider (mean $872, SD $249). Periprocedural imaging expenditures also varied by patient risk, with mean expenditures of $862 (SD $444) for patients with a CHADS2 score of ≥2 compared with $907 (SD $466) for CHADS2 score<2 (p<0.001). In conclusion, periprocedural imaging accounts for approximately 6% of mean Medicare expenditures for catheter ablation of AF. The expenditures for periprocedural imaging vary both at the patient and at the provider level and they are inversely related to stroke risk by CHADS2 score.
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Affiliation(s)
- Sean D Pokorney
- Duke Center for Atrial Fibrillation, Division of Cardiology, Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Bradley G Hammill
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Laura G Qualls
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Benjamin A Steinberg
- Duke Center for Atrial Fibrillation, Division of Cardiology, Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Lesley H Curtis
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Jonathan P Piccini
- Duke Center for Atrial Fibrillation, Division of Cardiology, Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina.
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Shurrab M, Schilling R, Gang E, Khan EM, Crystal E. Robotics in invasive cardiac electrophysiology. Expert Rev Med Devices 2014; 11:375-81. [DOI: 10.1586/17434440.2014.916207] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Fitzgerald DM. Catheter ablation of atrial fibrillation: to freeze, or not to freeze, that is the question. J Cardiovasc Electrophysiol 2013; 25:8-10. [PMID: 24112780 DOI: 10.1111/jce.12275] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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