Key result
Routine transoesophageal echocardiography prior to pulmonary vein isolation reduced debilitating strokes (OR 0.23; 95% CI 0.15-0.33) but incurred a considerable cost of $226,608 per QALY.
Why the study?
Does routine TEE prior to PVI reduce cerebral thrombo-embolic events and is it cost-effective in patients with symptomatic atrial fibrillation?
Does routine TEE prior to PVI reduce cerebral thrombo-embolic events and is it cost-effective in patients with symptomatic atrial fibrillation?
Effect estimate: OR 0.23 (95% CI 0.15-0.33)
Routine TEE prior to PVI reduces stroke and TIA risk but is associated with a high cost per QALY in unselected patients, whereas it is highly cost-effective in high-risk patients.
May support selective TEE in high-risk AF patients before PVI; leaves open routine use given unfavorable cost per QALY in unselected cohorts.
AIMS: The practice of routine vs. selective transoesophageal echocardiography (TEE) surveillance for left atrial appendage or intracavitary thrombus prior to pulmonary vein isolation (PVI) varies widely as evidence to guide this decision in terms of important clinical outcomes is lacking. METHODS AND RESULTS: We constructed a decision analysis model to compare the cost-effectiveness of routine TEE for detection of left atrial thrombus vs. no TEE. The model incorporated health outcomes and costs. Markov methodology was used to follow patients as they transition through varying health states. We examined a hypothetical cohort of patients with symptomatic atrial fibrillation suitable for PVI, and expected outcomes were modelled over a period of 2 years. Simulated patients (SPs) undergoing a strategy of a routine TEE experienced significantly fewer transient ischemic attacks (TIAs) [OR 0.28 (0.22-0.37)], and debilitating strokes [OR 0.23 (0.15-0.33)]. Routine TEE led to an absolute risk reduction for stroke of 1.2% [number needed to treat (NNT) 84 (79-100)] and 1.9% for TIA [NNT 53 (48-59)]. The incremental cost-effectiveness ratio (ICER) for TEE was $226,608 per quality-adjusted life year (QALY). The ICER for TEE among high-risk SPs, with pre-existing clot in the left atrium, was $2232 per QALY. CONCLUSION: Decision analysis and microsimulation suggest that routine use of TEE in an unselected population prior to PVI lowers the incidence of cerebral thrombo-embolic events but with considerable cost per QALY.
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Gula et al. (2010) studied Symptomatic atrial fibrillation. Routine transoesophageal echocardiography (TEE) vs. No TEE was evaluated on Debilitating strokes (OR 0.23, 95% CI 0.15-0.33). Routine transoesophageal echocardiography prior to pulmonary vein isolation reduced debilitating strokes (OR 0.23; 95% CI 0.15-0.33) but incurred a considerable cost of $226,608 per QALY.