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Catheter ablation for ventricular tachycardia (VT) in post-myocardial infarction (MI) patients with implanted cardioverter-defibrillators (ICDs) was cost effective, largely after trying the antiarrhythmia drug amiodarone (Pacerone), a trial substudy showed.
The procedure was more expensive than escalating drug therapy ($65,126 versus $60,269 in Canadian dollars over the 3-year follow-up period) -- "primarily due to the initial costs of ablation which were partially offset by the costs of subsequent ablations and adverse outcomes in the escalated drug therapy arm," John Sapp, MD, of the QEII Health Sciences Centre in Halifax, Nova Scotia, and colleagues wrote in .
But ablation also yielded greater quality-adjusted life-years (QALYs, 1.63 versus 1.49, difference 0.14, 95% CI -0.20 to 0.46), for an incremental cost per QALY gained of $34,057 versus escalated medication alone in the VANISH trial -- which included 259 patients, mostly from Canada, with an ICD implanted after MI who were having VT despite antiarrhythmic medication randomized to escalation of that therapy or ablation.
"At a willingness to pay (WTP) threshold of $50,000 per QALY, there is a 57% probability that ablation is more cost effective based on the analysis of the total trial population," the researchers wrote. They acknowledged the "substantial uncertainty with respect to this finding," but added that "the corollary, of course, is that the probability that escalated therapy is cost effective is 43%."
Notably, this advantage was seen in amiodarone-refractory VT (1.48 versus 1.26 QALYs, difference 0.22, 95% CI -0.19 to 0.59) but not in sotalol-refractory VT (1.90 QALYs for both, and $60,455 versus $45,033 Canadian dollars in costs).
"For amiodarone-refractory patients, there is a 75% probability that ablation is more cost effective than escalated therapy; whereas, in sotalol-refractory patients, there is a 24% probability that ablation is the more cost-effective strategy, at the same threshold," Sapp et al wrote.
They noted, however, that the relatively small numbers in the amiodarone and sotalol subgroups were a limitation, but suggested that the findings likely are generalizable outside of Canada.
Disclosures
The VANISH trial was funded by the Canadian Institutes of Health Research, with supplemental funding from St. Jude Medical and Biosense Webster.
Sapp reported financial relationships with St. Jude Medical and Biosense Webster.
Primary Source
JACC: Clinical Electrophysiology
Coyle K, et al "Cost effectiveness of ventricular tachycardia ablation versus escalation of antiarrhythmic drug therapy in the VANISH Trial" JACC Clin Electrophysiol 2018; DOI: 10.1016/j.jacep.2018.01.007.