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Hewage SA, Noviyani R, Brain D, Sharma P, Parsonage W, McPhail SM, Barnett A, Kularatna S. Cost-effectiveness of left atrial appendage closure for stroke prevention in atrial fibrillation: a systematic review appraising the methodological quality. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2023; 21:76. [PMID: 37872572 PMCID: PMC10591401 DOI: 10.1186/s12962-023-00486-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 10/10/2023] [Indexed: 10/25/2023] Open
Abstract
BACKGROUND The increasing global prevalence of atrial fibrillation (AF) has led to a growing demand for stroke prevention strategies, resulting in higher healthcare costs. High-quality economic evaluations of stroke prevention strategies can play a crucial role in maximising efficient allocation of resources. In this systematic review, we assessed the methodological quality of such economic evaluations. METHODS We searched electronic databases of PubMed, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, and Econ Lit to identify model-based economic evaluations comparing the left atrial appendage closure procedure (LAAC) and oral anticoagulants published in English since 2000. Data on study characteristics, model-based details, and analyses were collected. The methodological quality was evaluated using the modified Economic Evaluations Bias (ECOBIAS) checklist. For each of the 22 biases listed in this checklist, studies were categorised into one of four groups: low risk, partial risk, high risk due to inadequate reporting, or high risk. To gauge the overall quality of each study, we computed a composite score by assigning + 2, 0, - 1 and - 2 to each risk category, respectively. RESULTS In our analysis of 12 studies, majority adopted a healthcare provider or payer perspective and employed Markov Models with the number of health states varying from 6 to 16. Cost-effectiveness results varied across studies. LAAC displayed a probability exceeding 50% of being the cost-effective option in six out of nine evaluations compared to warfarin, six out of eight evaluations when compared to dabigatran, in three out of five evaluations against apixaban, and in two out of three studies compared to rivaroxaban. The methodological quality scores for individual studies ranged from 10 to - 12 out of a possible 24. Most high-risk ratings were due to inadequate reporting, which was prevalent across various biases, including those related to data identification, baseline data, treatment effects, and data incorporation. Cost measurement omission bias and inefficient comparator bias were also common. CONCLUSIONS While most studies concluded LAAC to be the cost-effective strategy for stroke prevention in AF, shortcomings in methodological quality raise concerns about reliability and validity of results. Future evaluations, free of these shortcomings, can yield stronger policy evidence.
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Affiliation(s)
- Sumudu A Hewage
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, Queensland University of Technology, No.61, Musk Avenue, Kelvin Grove, QLD, 4059, Australia.
| | - Rini Noviyani
- Department of Pharmacy, Udayana University, Bali, Indonesia
| | - David Brain
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, Queensland University of Technology, No.61, Musk Avenue, Kelvin Grove, QLD, 4059, Australia
| | - Pakhi Sharma
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, Queensland University of Technology, No.61, Musk Avenue, Kelvin Grove, QLD, 4059, Australia
| | - William Parsonage
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, Queensland University of Technology, No.61, Musk Avenue, Kelvin Grove, QLD, 4059, Australia
- Cardiology department, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Steven M McPhail
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, Queensland University of Technology, No.61, Musk Avenue, Kelvin Grove, QLD, 4059, Australia
- Digital Health and Informatics Directorate, Metro South Health, Brisbane, QLD, Australia
| | - Adrian Barnett
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, Queensland University of Technology, No.61, Musk Avenue, Kelvin Grove, QLD, 4059, Australia
| | - Sanjeewa Kularatna
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, Queensland University of Technology, No.61, Musk Avenue, Kelvin Grove, QLD, 4059, Australia
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Okafor C, Byrnes J, Stewart S, Scuffham P, Afoakwah C. Cost Effectiveness of Strategies to Manage Atrial Fibrillation in Middle- and High-Income Countries: A Systematic Review. PHARMACOECONOMICS 2023; 41:913-943. [PMID: 37204698 PMCID: PMC10322963 DOI: 10.1007/s40273-023-01276-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/18/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) remains the most common form of cardiac arrhythmia. Management of AF aims to reduce the risk of stroke, heart failure and premature mortality via rate or rhythm control. This study aimed to review the literature on the cost effectiveness of treatment strategies to manage AF among adults living in low-, middle- and high-income countries. METHODS We searched MEDLINE (OvidSp), Embase, Web of Science, Cochrane Library, EconLit and Google Scholar for relevant studies between September 2022 and November 2022. The search strategy involved medical subject headings or related text words. Data management and selection was performed using EndNote library. The titles and abstracts were screened followed by eligibility assessment of full texts. Selection, assessment of the risk of bias within the studies, and data extraction were conducted by two independent reviewers. The cost-effectiveness results were synthesised narratively. The analysis was performed using Microsoft Excel 365. The incremental cost effectiveness ratio for each study was adjusted to 2021 USD values. RESULTS Fifty studies were included in the analysis after selection and risk of bias assessment. In high-income countries, apixaban was predominantly cost effective for stroke prevention in patients at low and moderate risk of stroke, while left atrial appendage closure (LAAC) was cost effective in patients at high risk of stroke. Propranolol was the cost-effective choice for rate control, while catheter ablation and the convergent procedure were cost-effective strategies in patients with paroxysmal and persistent AF, respectively. Among the anti-arrhythmic drugs, sotalol was the cost-effective strategy for rhythm control. In middle-income countries, apixaban was the cost-effective choice for stroke prevention in patients at low and moderate risk of stroke while high-dose edoxaban was cost effective in patients at high risk of stroke. Radiofrequency catheter ablation was the cost-effective option in rhythm control. No data were available for low-income countries. CONCLUSION This systematic review has shown that there are several cost-effective strategies to manage AF in different resource settings. However, the decision to use any strategy should be guided by objective clinical and economic evidence supported by sound clinical judgement. REGISTRATION CRD42022360590.
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Affiliation(s)
- Charles Okafor
- Centre for Applied Health Economics, School of Medicine and Dentistry, Griffith University, 170 Kessels Road, Nathan, QLD, 4111, Australia
- Menzies Health Institute Queensland, Griffith University, Southport, QLD, Australia
| | - Joshua Byrnes
- Centre for Applied Health Economics, School of Medicine and Dentistry, Griffith University, 170 Kessels Road, Nathan, QLD, 4111, Australia
- Menzies Health Institute Queensland, Griffith University, Southport, QLD, Australia
| | - Simon Stewart
- Menzies Health Institute Queensland, Griffith University, Southport, QLD, Australia
- Institute for Health Research, University of Notre Dame Australia, Freemantle, WA, Australia
| | - Paul Scuffham
- Centre for Applied Health Economics, School of Medicine and Dentistry, Griffith University, 170 Kessels Road, Nathan, QLD, 4111, Australia
- Menzies Health Institute Queensland, Griffith University, Southport, QLD, Australia
| | - Clifford Afoakwah
- Centre for Applied Health Economics, School of Medicine and Dentistry, Griffith University, 170 Kessels Road, Nathan, QLD, 4111, Australia.
- Menzies Health Institute Queensland, Griffith University, Southport, QLD, Australia.
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Zahid S, Hashem A, Rai D, Khan MZ, Ullah W, Gowda S, Munir MB, Tan BEX, Velagapudi P, Naidu S, Goel S, Bhatt DL, Depta JP. Same-Day Discharge after Percutaneous Left Atrial Appendage Closure: Insights from the Nationwide Readmission Database 2015-2019. Curr Probl Cardiol 2023; 48:101588. [PMID: 36638903 DOI: 10.1016/j.cpcardiol.2023.101588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 01/03/2023] [Indexed: 01/13/2023]
Abstract
Data on the feasibility of same-day discharge (SDD) following percutaneous left atrial appendage closure (LAAC) remain limited. We analyzed the US Nationwide Readmission Database from quarter four of 2015 to 2019 to study the safety and feasibility of SDD after LAAC. After excluding non-elective cases and in-hospital deaths, a total of 54,880 cases of LAAC were performed during the study period. Following LAAC, 2% (n=1077) of patients underwent SDD, 88% (n=48,428) underwent next-day discharge (NDD), 5.2% (n=2881) were discharged on the second day (ScD), and 4.5% of patients (n = 2494) were discharged 3 or more days after LAAC. There was no difference in 30-day readmission rates between SDD and NDD (7.3% [n=79] vs 7.4% [n=3585], P=0.94). The hospitalization costs were significantly lower for SDD compared with NDD ($22,963 vs $27,079, P≤0.01). SDD discharge following percutaneous LAAC appears to be safe and is associated with lower hospitalization costs. Further prospective studies are needed to determine the safety and feasibility of SDD with percutaneous LAAC.
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Affiliation(s)
- Salman Zahid
- Sands-Constellation Heart Institute, Rochester General Hospital, Rochester, NY
| | - Anas Hashem
- Sands-Constellation Heart Institute, Rochester General Hospital, Rochester, NY
| | - Devesh Rai
- Sands-Constellation Heart Institute, Rochester General Hospital, Rochester, NY
| | - Muhammad Zia Khan
- Division of Cardiovascular Medicine, West Virginia University Heart & Vascular Institute, Morgantown, WV
| | - Waqas Ullah
- Department of Cardiovascular Medicine, Jefferson University Hospitals, Philadelphia, PA
| | - Smitha Gowda
- Houston Methodist DeBakey Heart & Vascular Center, Houston, TX
| | - Muhammad Bilal Munir
- Division of Cardiovascular Medicine, University of California (San Diego) Medical Center, La Jolla, CA
| | - Bryan E-Xin Tan
- Sands-Constellation Heart Institute, Rochester General Hospital, Rochester, NY
| | - Poonam Velagapudi
- Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Srihari Naidu
- Department of Cardiovascular Medicine, Westchester Medical Center, Westchester, NY
| | - Sachin Goel
- Houston Methodist DeBakey Heart & Vascular Center, Houston, TX
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, New York, NY.
| | - Jeremiah P Depta
- Sands-Constellation Heart Institute, Rochester General Hospital, Rochester, NY
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Petrou P. Cost-effectiveness of Left Atrial Appendage Closure with WATCHMAN device for non-valvular atrial fibrillation patients in Japan. Are the policy implications big in Japan? J Med Econ 2023; 26:1301-1302. [PMID: 37794807 DOI: 10.1080/13696998.2023.2267392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 09/18/2023] [Indexed: 10/06/2023]
Affiliation(s)
- Panagiotis Petrou
- Department of Health Sciences, School of Pharmacy, Pharmacoepidemiology- Pharmacovigilance, University of Nicosia, Nicosia, Cyprus
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Chew DS, Zhou K, Pokorney SD, Matchar DB, Vemulapalli S, Allen LA, Jackson KP, Samad Z, Patel MR, Freeman JV, Piccini JP. Left Atrial Appendage Occlusion Versus Oral Anticoagulation in Atrial Fibrillation : A Decision Analysis. Ann Intern Med 2022; 175:1230-1239. [PMID: 35969865 DOI: 10.7326/m21-4653] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Left atrial appendage occlusion (LAAO) is a potential alternative to oral anticoagulants in selected patients with atrial fibrillation (AF). Compared with anticoagulants, LAAO decreases major bleeding risk, but there is uncertainty regarding the risk for ischemic stroke compared with anticoagulation. OBJECTIVE To determine the optimal strategy for stroke prevention conditional on a patient's individual risks for ischemic stroke and bleeding. DESIGN Decision analysis with a Markov model. DATA SOURCES Evidence from the published literature informed model inputs. TARGET POPULATION Women and men with nonvalvular AF and without prior stroke. TIME HORIZON Lifetime. PERSPECTIVE Clinical. INTERVENTION LAAO versus warfarin or direct oral anticoagulants (DOACs). OUTCOME MEASURES The primary end point was clinical benefit measured in quality-adjusted life-years. RESULTS OF BASE-CASE ANALYSIS The baseline risks for stroke and bleeding determined whether LAAO was preferred over anticoagulants in patients with AF. The combined risks favored LAAO for higher bleeding risk, but that benefit became less certain at higher stroke risks. For example, at a HAS-BLED score of 5, LAAO was favored in more than 80% of model simulations for CHA2DS2-VASc scores between 2 and 5. The probability of LAAO benefit in QALYs (>80%) at lower bleeding risks (HAS-BLED score of 0 to 1) was limited to patients with lower stroke risks (CHA2DS2-VASc score of 2). Because DOACs carry lower bleeding risks than warfarin, the net benefit of LAAO is less certain than that of DOACs. RESULTS OF SENSITIVITY ANALYSIS Results were consistent using the ORBIT bleeding score instead of the HAS-BLED score, as well as alternative sources for LAAO clinical effectiveness data. LIMITATION Clinical effectiveness data were drawn primarily from studies on the Watchman device. CONCLUSION Although LAAO could be an alternative to anticoagulants for stroke prevention in patients with AF and high bleeding risk, the overall benefit from LAAO depends on the combination of stroke and bleeding risks in individual patients. These results suggest the need for a sufficiently low stroke risk for LAAO to be beneficial. The authors believe that these results could improve shared decision making when selecting patients for LAAO. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Derek S Chew
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, and Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada (D.S.C.)
| | - Ke Zhou
- Duke-National University of Singapore Medical School, Singapore (K.Z.)
| | - Sean D Pokorney
- Duke Clinical Research Institute, Duke University, and Division of Cardiology, Duke University Medical Center, Durham, North Carolina (S.D.P., S.V., M.R.P., J.P.P.)
| | - David B Matchar
- Duke-National University of Singapore Medical School, Singapore, and Division of General Internal Medicine, Duke University Medical Center, Durham, North Carolina (D.B.M.)
| | - Sreekanth Vemulapalli
- Duke Clinical Research Institute, Duke University, and Division of Cardiology, Duke University Medical Center, Durham, North Carolina (S.D.P., S.V., M.R.P., J.P.P.)
| | - Larry A Allen
- University of Colorado School of Medicine, Aurora, Colorado (L.A.A.)
| | - Kevin P Jackson
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina (K.P.J.)
| | - Zainab Samad
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, and Department of Medicine, Aga Khan University, Karachi, Pakistan (Z.S.)
| | - Manesh R Patel
- Duke Clinical Research Institute, Duke University, and Division of Cardiology, Duke University Medical Center, Durham, North Carolina (S.D.P., S.V., M.R.P., J.P.P.)
| | - James V Freeman
- Yale University School of Medicine, New Haven, Connecticut (J.V.F.)
| | - Jonathan P Piccini
- Duke Clinical Research Institute, Duke University, and Division of Cardiology, Duke University Medical Center, Durham, North Carolina (S.D.P., S.V., M.R.P., J.P.P.)
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D'Ancona G, Arslan F, Safak E, Weber D, Al Ammareen R, Ince H. Actual management costs of patients with non-valvular atrial fibrillation treated with percutaneous left atrial appendage closure or oral anticoagulation. Int J Cardiol 2021; 351:61-64. [PMID: 34929249 DOI: 10.1016/j.ijcard.2021.12.027] [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] [Received: 11/01/2021] [Revised: 12/01/2021] [Accepted: 12/15/2021] [Indexed: 11/17/2022]
Abstract
AIMS Comparing actual management costs in patients with non-valvular atrial fibrillation (AF) treated with percutaneous left atrial appendage closure (LAAC) or OAC only. METHODS AND RESULTS Patients undergoing percutaneous LAAC and AF patients treated with OAC only were matched for gender, age, and diagnosis related groups (DRG) clinical complexity level (CCL). Costs for cardiovascular outpatient clinic visits and hospitalizations were derived from the actual reimbursement records. Between 1/2012 and 12/2016, 8478 patients were referred: 7801 (92%) managed with OAC and 677 (8%) with percutaneous LAAC. Matching resulted in 558 patients (279 per group) for final analysis. Age was 74.9 ± 7.5 years, 244 were female (43.7%), and DRG CCL was 1.8 ± 1.1. Annualized management cost before percutaneous LAAC was € 3110 (IQR: € 1281-8127). After 4.5 ± 1.4 years follow-up, annualized management cost was € 1297 (IQR: € 607-2735) in OAC patients and € 1013 (IQR: € 0-4770) in patients after percutaneous LAAC (p = 0.003). Percutaneous LAAC was the strongest independent determinant to reduce follow-up costs (B = -0.8; CI: -1.09 ̶̶̶̶̶ -0.6; p < 0.0001). Estimated 3-year survival was 92% in percutaneous LAAC and 90% in OAC patients (p = 0.7). CONCLUSION Percutaneous LAAC significantly reduces management costs. Management costs are significantly higher for patients treated with only OAC compared to patients after percutaneous LAAC. In spite of their complex comorbid profile, percutaneous LAAC patients show a follow-up survival rate similar to patients solely treated with OAC. Future studies are necessary to investigate the potential net economic and clinical benefit of percutaneous LAAC in patients treated with OAC only.
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Affiliation(s)
- Giuseppe D'Ancona
- Department of Cardiology, Vivantes Klinikum Am Urban and im Friedrichshain, Berlin, Germany and Rostock University, Rostock, Germany.
| | - Fatih Arslan
- Department of Cardiology, Vivantes Klinikum Am Urban and im Friedrichshain, Berlin, Germany and Rostock University, Rostock, Germany; Department of Cardiology, Leiden University Medical Center, Leiden, NL, the Netherlands
| | - Erdal Safak
- Department of Cardiology, Vivantes Klinikum Am Urban and im Friedrichshain, Berlin, Germany and Rostock University, Rostock, Germany
| | - Denise Weber
- Department of Cardiology, Vivantes Klinikum Am Urban and im Friedrichshain, Berlin, Germany and Rostock University, Rostock, Germany
| | - Raid Al Ammareen
- Department of Cardiology, Vivantes Klinikum Am Urban and im Friedrichshain, Berlin, Germany and Rostock University, Rostock, Germany
| | - Hüseyin Ince
- Department of Cardiology, Vivantes Klinikum Am Urban and im Friedrichshain, Berlin, Germany and Rostock University, Rostock, Germany
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Left atrial appendage closure with the watchman device reduces atrial fibrillation management costs. Clin Res Cardiol 2021; 111:105-113. [PMID: 34652527 DOI: 10.1007/s00392-021-01943-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 09/14/2021] [Indexed: 10/20/2022]
Abstract
AIMS To report hospitalization costs of patients with non-valvular atrial fibrillation (AF) submitted to percutaneous left atrial appendage closure (LAAC) with the Watchman device. METHODS Pre- and post-procedural hospitalization AF-related costs were calculated using the DRG system (diagnosis-related groups) and compared. RESULTS Between 2012 and 2016, 677 non-valvular AF patients underwent LAAC. Median time from first cardiac hospitalization to LAAC was 5.9 years (IQR 1.6-9.1) and median follow-up after LAAC was 4.8 years (IQR 3.6-5.6). LAAC mortality was 1.3% and follow-up mortality 16.9%. Median pre-LAAC hospitalization cost was € 17,867 (IQR € 7512-35,08) and post-LAAC € 8772 (IQR € 1183-25,159) (p < 0.0001). Annualized cost pre-LAAC was 3773 € (IQR € 1644-8,493) and post-LAAC 2,001 € (IQR € 260-6913) (p < 0.0001). Follow-up survivors had significantly lower post-LAAC costs (p < 0.0001) and after a survival cut-off time of 4.6 years LAAC procedural and post-procedural hospitalization costs achieved parity with pre-LACC costs (AUC 0.64; p = 0.02). CHA2DS2-VASc score (B = 0.04; p = 0.02; 95% CI 0.006-0.08), and HAS-BLED score (B = 0.08; p = 0.004; 95% CI 0.02-0.14) were independent determinants for annualized hospitalization costs post-LAAC. At Cox-regression analysis the DRG mean clinical complexity level (CCL) was the only independent determinant for follow-up mortality (OR = 2.2; p < 0.0001; 95% CI 1.6-2.8) with a cut-off value of 2.25 to predict follow-up mortality (AUC 0.72; p < 0.0001; Spec. 70%; Sens. 70%). CONCLUSION Hospitalization costs pre-LAAC are consistent, and after LAAC, they are significantly reduced. Costs seem related to the patient's risk profile at the time of the procedure. With the increase in post-LAAC survival time, the procedure becomes economically more profitable.
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Cruz Neto J, Barros LDO, Morais SSFD, Silva MGCD. Review of cost-effectiveness of antithrombotic alternatives in patients with atrial fibrillation. Rev Assoc Med Bras (1992) 2021; 67:1050-1055. [DOI: 10.1590/1806-9282.20210332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 06/06/2021] [Indexed: 11/22/2022] Open
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9
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D'Ancona G, Safak E, Ince H. Left atrial appendage occlusion in patients with atrial fibrillation and high risk of fall: a clinical dilemma or a budgetary issue? Clin Res Cardiol 2019; 108:1406-1407. [PMID: 30989317 DOI: 10.1007/s00392-019-01476-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 04/05/2019] [Indexed: 11/26/2022]
Affiliation(s)
- Giuseppe D'Ancona
- Department of Cardiology, Vivantes Klinikum im Friedrichshain und Am Urban, Dieffenbachstraße 1, 10967, Berlin, Germany.
- Rostock University Medical Center, Rostock, Germany.
| | - Erdal Safak
- Department of Cardiology, Vivantes Klinikum im Friedrichshain und Am Urban, Dieffenbachstraße 1, 10967, Berlin, Germany
- Rostock University Medical Center, Rostock, Germany
| | - Hüseyin Ince
- Department of Cardiology, Vivantes Klinikum im Friedrichshain und Am Urban, Dieffenbachstraße 1, 10967, Berlin, Germany
- Rostock University Medical Center, Rostock, Germany
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Cheung GS, So KC, Chan CK, Chan AK, Lee APW, Lam YY, Yan BP. Comparison of three left atrial appendage occlusion devices for stroke prevention in patients with non-valvular atrial fibrillation: a single-centre seven-year experience with WATCHMAN, AMPLATZER Cardiac Plug/Amulet, LAmbre: Comparison of three LAAO devices for stroke prevention. ASIAINTERVENTION 2019; 5:57-63. [PMID: 34912974 PMCID: PMC8525730 DOI: 10.4244/aij-d-18-00013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 10/11/2018] [Indexed: 05/30/2023]
Abstract
AIMS We aimed to compare long-term "real-world" outcomes of three left atrial appendage occlusion (LAAO) devices for stroke prevention in a Chinese population with non-valvular atrial fibrillation (NVAF). METHODS AND RESULTS Consecutive patients who underwent LAAO from June 2009 to October 2016 at a university-affiliated hospital were retrospectively analysed. In-hospital and major adverse events (MAE) including mortality, stroke and major bleeding rates were compared by LAAO device. One hundred and sixty-one (161) patients (mean age 71.4±8.2 years; 67.7% male) with mean CHA2DS2-VASc score of 4.1±1.6 and HAS-BLED score of 2.9±1.1 underwent 162 LAAO procedures, of which 47.5% (n=77), 41.4% (n=67) and 11.1% (n=18) were AMPLATZER Cardiac Plug (ACP)/Amulet, WATCHMAN and LAmbre, respectively. The procedural success rate was 97.5% (158/162). The in-hospital adverse event rate was 7.4% (12/162) and comparable among devices (p=NS). Mean follow-up duration was 28.3±24.4 months (373 patient-years). There were no significant differences in long-term MAE rates among devices (p=NS). Observed annual ischaemic stroke (1.1% vs. 5.1%, p<0.001) and major bleeding rates (2.7% vs. 4.5%, p=NS) were lower compared with the predicted rates, respectively. CONCLUSIONS The WATCHMAN, ACP/Amulet and LAmbre LAAO devices demonstrated similar long-term safety and efficacy in prevention of ischaemic stroke and major bleeding in patients with NVAF.
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Affiliation(s)
- Gary Sh Cheung
- Division of Cardiology, Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong and Prince of Wales Hospital, Hong Kong SAR, China
| | - Kent Cy So
- Division of Cardiology, Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong and Prince of Wales Hospital, Hong Kong SAR, China
| | - Christy Ky Chan
- Division of Cardiology, Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong and Prince of Wales Hospital, Hong Kong SAR, China
| | - Anna Ky Chan
- Division of Cardiology, Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong and Prince of Wales Hospital, Hong Kong SAR, China
| | - Alex Pui-Wai Lee
- Division of Cardiology, Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong and Prince of Wales Hospital, Hong Kong SAR, China
| | - Yat-Yin Lam
- Center Medical, Suite 1201, Central Building, Central, Hong Kong SAR, China
| | - Bryan P Yan
- Division of Cardiology, Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong and Prince of Wales Hospital, Hong Kong SAR, China
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Nédellec E, Pineau J, Prognon P, Martelli N. Level of Evidence in Economic Evaluations of Left Atrial Appendage Closure Devices: A Systematic Review. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2018; 16:793-802. [PMID: 30171480 DOI: 10.1007/s40258-018-0429-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVES The objective of the present work was to assess the level of evidence in economic evaluations of percutaneous left atrial appendage closure devices, and to test the complementarity of three different tools for assessing the quality of economic evaluations. METHODS We conducted a systematic review of articles in English or French listed in MEDLINE, Embase, Cochrane, the Cost-Effectiveness Analysis registry and the National Health Service Economic Evaluation Database. We included only economic evaluations concerning left atrial appendage closure devices. Data were extracted from articles by two authors working independently and using three analysis grids to measure the quality of economic evaluations [the British Medical Journal (BMJ) checklist, the hierarchy scale developed by Cooper et al. (J Health Serv Res Policy 10:245-50, 2005) and the Quality of Health Economic Studies (QHES) instrument]. RESULTS Seven economic evaluations met our inclusion criteria. All were published between 2013 and 2016. All were cost-utility analyses, and fully complied with the BMJ checklist. According to the hierarchy scale developed by Cooper et al., the quality of data used was heterogeneous. Finally, the mean score for the seven economic studies was 90/100 with the QHES instrument. CONCLUSIONS Despite the recent development of left atrial appendage closure devices, most economic evaluations conducted here were well-designed studies. Furthermore, different tools used to assess the quality of these studies were complementary, but none gave a global vision of the quality of economic studies.
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Affiliation(s)
- Etienne Nédellec
- Pharmacy Department, Georges Pompidou European Hospital, AP-HP, 20 rue Leblanc, 75015, Paris, France
| | - Judith Pineau
- Pharmacy Department, Georges Pompidou European Hospital, AP-HP, 20 rue Leblanc, 75015, Paris, France
| | - Patrice Prognon
- Pharmacy Department, Georges Pompidou European Hospital, AP-HP, 20 rue Leblanc, 75015, Paris, France
| | - Nicolas Martelli
- Pharmacy Department, Georges Pompidou European Hospital, AP-HP, 20 rue Leblanc, 75015, Paris, France.
- Université Paris-Sud, Université Paris-Saclay, EA7358 GRADES, 5 rue Jean-Baptiste Clément, 92290, Châtenay-Malabry, France.
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Du X, Chu H, Ye P, He B, Xu H, Jiang S, Lin M, Lin R, Liu J, Wang B, Feng M, Yu Y, Chen X. Combination of left atrial appendage closure and catheter ablation in a single procedure for patients with atrial fibrillation: Multicenter experience. J Formos Med Assoc 2018; 118:891-897. [PMID: 30482569 DOI: 10.1016/j.jfma.2018.10.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 09/26/2018] [Accepted: 10/04/2018] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND/PURPOSE Experience in procedures combining left atrial appendage (LAA) closure (LAAC) and catheter ablation (CA) was scarce in Chinese nonvalvular atrial fibrillation (AF) patients with high risks for stroke and bleeding. We aimed to investigate the efficacy and safety of the combination therapy with LAAC and AF CA in a single procedure based on the multicenter data and medium-term follow-up results. METHODS A total of 122 AF patients with a mean CHA2DS2-VASc score of 4.3 ± 1.4 and HAS-BLED score of 3.3 ± 1.0 were enrolled. The Watchman (n = 83) devices were implanted either before or after AF ablations in the same procedure, while the Amplatzer Cardiac Plug (ACP, n = 39) devices were implanted immediately after CA. AF recurrence and transesophageal echocardiography results were evaluated. RESULTS All devices were successfully implanted and acute complete LAA occlusions were achieved in 115 (94.3%) of patients. Neither acute nor chronic peri-device leaks greater than 5 mm were detected. Oral anticoagulation was held in all patients but two with asymptomatic device-related thrombi, which were resolved after prolonged anticoagulation. AF-free success rate without antiarrhythmic drugs was 76.2% after a mean follow-up of 11.5 ± 6.8 months. No serious complications were observed during the follow-up. CONCLUSION The combination therapy with LAAC and AF ablation in a single procedure was efficacious and safe in the Chinese symptomatic AF population with high risk for stroke and bleeding.
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Affiliation(s)
- Xianfeng Du
- Ningbo First Hospital, Zhejiang University, Ningbo, 315010, China
| | - Huimin Chu
- Ningbo First Hospital, Zhejiang University, Ningbo, 315010, China.
| | - Ping Ye
- The Central Hospital of Wuhan, Wuhan, 325000, China
| | - Bin He
- Ningbo First Hospital, Zhejiang University, Ningbo, 315010, China
| | - Huaiqin Xu
- The Second Affiliated Hospital of Hainan Medical University, Haikou, 570311, China
| | - Shubin Jiang
- The Hospital of Traditional Chinese Medicine of the Xinjiang Uygur Autonomous Region, Xinjiang Medical University, Urumchi, 830000, China
| | - Miao Lin
- Wenzhou Central Hospital, Wenzhou, 325000, China
| | - Rong Lin
- Quanzhou First Hospital, Fujian Medical University, Quanzhou, 362002, China
| | - Jing Liu
- Ningbo First Hospital, Zhejiang University, Ningbo, 315010, China
| | - Binhao Wang
- Ningbo First Hospital, Zhejiang University, Ningbo, 315010, China
| | - Mingjun Feng
- Ningbo First Hospital, Zhejiang University, Ningbo, 315010, China
| | - Yibo Yu
- Ningbo First Hospital, Zhejiang University, Ningbo, 315010, China
| | - Xiaomin Chen
- Ningbo First Hospital, Zhejiang University, Ningbo, 315010, China
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Left Atrial Appendage Closure Device With Delivery System: A Health Technology Assessment. ONTARIO HEALTH TECHNOLOGY ASSESSMENT SERIES 2017; 17:1-106. [PMID: 28744335 PMCID: PMC5515321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND Atrial fibrillation is a common cardiac arrhythmia, and 15% to 20% of those who have experienced stroke have atrial fibrillation. Treatment options to prevent stroke in people with atrial fibrillation include pharmacological agents such as novel oral anticoagulants or nonpharmacological devices such as the left atrial appendage closure device with delivery system (LAAC device). The objectives of this health technology assessment were to assess the clinical effectiveness and cost-effectiveness of the LAAC device versus novel oral anticoagulants in patients without contraindications to oral anticoagulants and versus antiplatelet agents in patients with contraindications to oral anticoagulants. METHODS We performed a systematic review and network meta-analysis. We also conducted an economic literature review, economic evaluation, and budget impact analysis to assess the cost-effectiveness and budget impact of the LAAC device compared with novel oral anticoagulants and oral antiplatelet agents (e.g., aspirin). We also spoke with patients to better understand their preferences, perspectives, and values. RESULTS Seven randomized controlled studies met the inclusion criteria for indirect comparison. Five studies assessed the effectiveness of novel oral anticoagulants versus warfarin, and two studies compared the LAAC device with warfarin. No studies were identified that compared the LAAC device with aspirin in patients in whom oral anticoagulants were contraindicated. Using the random effects model, we found that the LAAC device was comparable to novel oral anticoagulants in reducing stroke (odds ratio [OR] 0.85; credible interval [Cr.I] 0.63-1.05). Similarly, the reduction in the risk of all-cause mortality was comparable between the LAAC device and novel oral anticoagulants (OR 0.71; Cr.I 0.49-1.22). The LAAC device was found to be superior to novel oral anticoagulants in preventing hemorrhagic stroke (OR 0.45; Cr.I 0.29-0.79), whereas novel oral anticoagulants were found to be superior to the LAAC device in preventing ischemic stroke (OR 0.67; Cr.I 0.24-1.64). The body of clinical evidence was found to be of moderate quality as assed by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria. Results from the economic evaluation indicate that the LAAC device is cost-effective compared with aspirin in patients with contraindications to oral anticoagulants. In patients without contraindications to oral anticoagulants, we found that the LAAC device is not cost-effective compared with novel oral anticoagulants. Publicly funding the LAAC device in patients with nonvalvular atrial fibrillation with contraindications to oral anticoagulants could result in additional funding of $1.1 million to $7.7 million over the first five years. Patients interviewed reported on the impact of living with nonvalvular atrial fibrillation and were supportive of the LAAC device as a treatment option. CONCLUSIONS Moderate-quality evidence suggests that the LAAC device is as effective as novel oral anticoagulants in preventing stroke in people with nonvalvular atrial fibrillation. However, our results indicate that the LAAC device is cost-effective only in patients with contraindications to oral anticoagulants. People with nonvalvular atrial fibrillation with whom we spoke reported positive support for the LAAC device.
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