Cardiac resynchronisation therapy in patients with atrioventricular nodal disease and reduced ejection fraction - can we afford it?

BACKGROUND

Recent pacing guidelines from the European Society of Cardiology recommend cardiac resynchronisation therapy (CRT) in patients with an atrioventricular (AV) nodal pacing indication and reduced ejection fraction (EF). However, concerns over added expenditure may limit its widespread implementation. We investigate the potential incremental cost of biventricular over right ventricular pacing if such a practice was adopted.

METHODS

Retrospective analysis was performed of devices implanted over eight years. The database was analysed for device type, pacing indication and EF. Cost analysis was performed.

RESULTS

1751 devices were implanted over eight years at an averaged cost of AUD$1,369,125 per year. 172 with CRT were excluded. 25.4 (11.6%) patients per year had an EF≤50% and AV nodal disease. 18.4 were in sinus rhythm (SR) and 7.0 in atrial fibrillation (AF). Of these, 13.5 (6.2%) had EF≤45% (9.9 SR, 3.6 AF) and 8.2 (3.8%) had EF≤35% (5.6 SR, 2.6 AF). Based on an incremental cost of $4,000 per device, if all patients with EF≤50% received CRT, the total cost increment per year equates to $73,500 for SR patients or $101,500 if AF patients were included. In patients with EF≤35% and EF≤45%, this amounts to $22,500 and $39,500 per year for SR patients respectively or $33,000 and $54,000 per year if AF patients were included. Depending on the EF and rhythm, this represents a 1.6% to 7.4% increase per year in the pacing budget for an increased patient population of between 2.6% (EF≤35% in SR) to 11.6% (EF≤50%).

CONCLUSION

A small proportion of additional patients will qualify for CRT based on the chosen cut-off and rhythm. Although the individual incremental cost for biventricular over right ventricular pacing is high in patients with AV nodal disease and reduced EF, overall this represents at most, a modest increase in the total pacing budget.