COST-EFFECTIVENESS OF RADIOFREQUENCY ABLATION COMPARED WITH OTHER STRATEGIES IN WOLFF-PARKINSON-WHITE SYNDROME

Background. Patients with Wolff-Parkinson-White syndrome fall into fou r risk groups: those with (1) prior cardiac arrest, (2) paroxysmal sup raventricular tachycardia or atrial fibrillation (PSVT/AF) with hemody namic compromise, (3) PSVT/AF without hemodynamic compromise, and (4) no symptoms. Methods and Results. For each group, we developed a cost- effectiveness analysis examining five clinical management strategies: (1) observation, (2) observation until a cardiac arrest dictates the n eed for therapy, (3) initial drug therapy guided by noninvasive monito ring, (4) initial radiofrequency ablation (RFA), and (5) initial surgi cal ablation. We used a Markov simulation model to estimate life expec tancy and costs for patients whose ages are between 20 and 60 years. T he model includes the risks of cardiac arrest, PSVT/AF, drug side effe cts, procedure-related complications and mortality, the efficacy of dr ugs and RFA, and costs. Based on literature and expert opinion, we ass umed that the annual risks of cardiac arrest are 0.01%, 0.05%, and 0.5 %, respectively, in patients who are asymptomatic, who had PSVT/AF wit hout hemodynamic compromise, or who had PSVT/AF with hemodynamic compr omise. We also assumed that RFA has an overall efficacy of 92% in prev enting cardiac arrest and arrhythmias. Our model predicts that RFA sho uld yield a life expectancy greater than or equal to other strategies. In cardiac arrest survivors and patients who have had PSVT/AF with he modynamic compromise, our model suggests that RFA should both prolong survival and save resources. For patients with PSVT/AF without hemodyn amic compromise, the marginal cost-effectiveness of attempted RFA (fol lowed by conservative treatment if the RFA fails) ranges from $6600 pe r quality-adjusted life year (QALY) gained for 20-year-old patients to $19 000 per QALY gained for 60-year-old patients. For asymptomatic pa tients, RFA costs from $174 000 per QALY gained for 20-year-old patien ts to $540 000 per QALY gained for 60-year-old patients. Conclusions. Our analysis supports the emerging practice of performing RFA in patie nts with Wolff-Parkinson-White syndrome who survive cardiac arrest or who experience PSVT/AF but also supports the current practice of obser ving asymptomatic patients.