PO-03-175 COST-EFFECTIVENESS OF TRANSESOPHAGEAL ECHOCARDIOGRAM PRIOR TO ATRIAL FIBRILLATION ABLATION.

Abstract

With universal adoption of uninterrupted anticoagulation (AC) it is suggested that transesophageal echo (TEE) screening for LA (left atrial) thrombus prior to AF ablation procedure could be omitted. Observational studies suggest that post-procedure stroke might not be completely prevented by TEE. Accumulating data on safety of AF ablation on uninterrupted AC together with a risk of TEE complications raise the question of indications for TEE in all AF ablation patients. We estimated the cost-effectiveness of TEE before AF ablation. Cost-effectiveness ratio was defined as the net costs of TEE including the cost of TEE complications and reduction of lifetime stroke costs divided by net health benefit gain. Health effect was quality-adjusted life-years (QALYs) due to post-ablation stroke or TEE complications. Costs and QALYs were discounted at 3%. Lifetime cost of stroke was assessed according to the modified Rankin Scale (mRS) at 1 year follow up. One way sensitivity analyses were performed for the incidence of TEE complications, stroke rate and severity. We assumed double the rate and half the rate of TEE complications. For stroke severity sensitivity analysis we redistributed severity towards non-mild strokes having more weight. For the stroke rate we added the LA thrombus detection rate by TEE (2%) to the literature reported incidence of post ablation stroke. Given the rarity of stroke after AF ablation, and the uncertainty of TEE effectiveness in preventing it, we reviewed cost-effectiveness analysis based on hypothetical stroke reduction by TEE of 25%, 50%, 75% and 100%. When TEE does prevents no strokes, TEE is dominated, adding $434,802,162 in costs and reducing health by 768 QALYs in 240,000 procedures per year. When TEE prevents all peri-procedural strokes, the cost-effectiveness ratio is $45,620 per QALY gained. TEE remains a dominated strategy in sensitivity analyses if it doesn’t prevent any strokes. When strokes are reduced by 50%, the cost effectiveness ratio exceeds $100,000 Our study found that when TEE prior to AF ablation on uninterrupted AC doesn’t prevent any strokes, TEE is dominated. Cost-effectiveness of TEE screening is sensitive to the level of stroke prevention it accomplishes. For TEE to be cost effective it must reduce the risk of stroke at least by 50%. RCTs are needed on effectiveness of TEE at preventing strokes in patients on uninterrupted AC to fully resolve the utility of TEE.