title: Atrial flutter and atrial fibrillation ablation - sequential or combined? A cost-benefit and risk analysis of primary prevention pulmonary vein ablation.
abstract: Recent studies have tested the hypothesis that preventive pulmonary vein isolation (PVI) at time of atrial flutter ablation in patients who have not had atrial fibrillation (AF) will reduce future incidence of AF.
  
  
  
  To model relative procedural costs, risks, and benefits of sequential versus combined ablation strategies.
  
  
  
  The decision model compares a sequential ablation strategy of atrial flutter ablation, followed by future PVI if necessary, with an initial combined flutter and preventive PVI ablation strategy. Assumptions are AF incidence 20% per year, PVI success rate 70%, PVI complication rate 4%, atrial flutter complication rate 1%, and costs $13,056 for PVI and $8,466 for atrial flutter ablation.
  
  
  
  The sequential ablation strategy is less expensive, at 1.4 vs 1.6 expected flutter ablation equivalents (FAE) ($11,852 vs $13,545) per patient, and entails less average risk, at 2% vs 4%. A combined ablation strategy is more expensive if the relative cost of PVI is more than 24.6% higher than atrial flutter ablation. A combined ablation strategy has higher total risk if PVI procedural risk is 24.6% more than atrial flutter ablation.
  
  
  
  Under base case assumptions of relative cost of PVI to flutter ablation 1.5 and relative risk 4, a sequential ablation approach has less total expected cost and less expected risk. There appears to be no compelling reason to adopt a combined ablation approach into standard practice. Nomograms are presented to allow the reader to assess which strategy is preferred according to local relative costs and risk.
authors.affiliation: Arrhythmia Service, University Hospital, Western University, London, Canada. Electronic address: lgula@uwo.ca.
authors.forename: Lorne J
authors.initials: LJ
authors.lastname: Gula
authors.affiliation: Arrhythmia Service, University Hospital, Western University, London, Canada.
authors.forename: Allan C
authors.initials: AC
authors.lastname: Skanes
authors.affiliation: Arrhythmia Service, University Hospital, Western University, London, Canada.
authors.forename: George J
authors.initials: GJ
authors.lastname: Klein
authors.affiliation: Institute for Clinical Evaluative Sciences Western, London, Canada.
authors.forename: Krista B
authors.initials: KB
authors.lastname: Jenkyn
authors.affiliation: Arrhythmia Service, Queen's University, Kingston, Canada.
authors.forename: Damian P
authors.initials: DP
authors.lastname: Redfearn
authors.affiliation: Arrhythmia Service, University Hospital, Western University, London, Canada.
authors.forename: Jaimie
authors.initials: J
authors.lastname: Manlucu
authors.affiliation: Arrhythmia Service, University Hospital, Western University, London, Canada.
authors.forename: Jason D
authors.initials: JD
authors.lastname: Roberts
authors.affiliation: Arrhythmia Service, University Hospital, Western University, London, Canada.
authors.forename: Raymond
authors.initials: R
authors.lastname: Yee
authors.affiliation: Arrhythmia Service, University Hospital, Western University, London, Canada.
authors.forename: Anthony S L
authors.initials: AS
authors.lastname: Tang
authors.affiliation: Arrhythmia Service, University Hospital, Western University, London, Canada.
authors.forename: Peter
authors.initials: P
authors.lastname: Leong-Sit
mesh_terms: D000368:Aged; D001281:Atrial Fibrillation / Q000453:epidemiology / Q000601:surgery*; D001282:Atrial Flutter / Q000453:epidemiology / Q000601:surgery*; D002170:Canada / Q000453:epidemiology; D017115:Catheter Ablation / Q000009:adverse effects / Q000379:methods; D003362:Cost-Benefit Analysis; D005260:Female; D006801:Humans; D015994:Incidence; D008297:Male; D049451:Nomograms; D010043:Outcome and Process Assessment, Health Care; D011667:Pulmonary Veins / Q000601:surgery*; D012008:Recurrence; D020379:Risk Adjustment / Q000191:economics / Q000379:methods; D018570:Risk Assessment; D055502:Secondary Prevention / Q000191:economics / Q000379:methods; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000191:economics / Q000379:methods
keywords: Atrial fibrillation; Cost modeling; Decision analysis; Pulmonary vein isolation; Risk