Cost-Effectiveness of Various Risk Stratification Methods for Asymptomatic Ventricular Pre-Excitation

Study Questions:

What is the least costly technique for risk stratification in pediatric patients with a Wolff-Parkinson-White pattern on the electrocardiogram?

Methods:

This was a retrospective study of 102 pediatric patients with asymptomatic ventricular pre-excitation who underwent graded exercise testing (GXT), followed by transesophageal pacing testing (TEP), if there was not loss of pre-excitation during GXT. Catheter ablation (CA) of the accessory pathway (AP) was performed if TEP demonstrated a shortest pre-excited R-R interval during atrial fibrillation of ≤240 ms. Decision analysis modeling was used to compare the costs of various risk stratification methods versus CA for all patients.

Results:

GXT and TEP demonstrated a low-risk AP in 73% of the 102 patients. No further testing or therapy was provided for these patients. The remaining 27% of patients underwent successful CA of the AP. Compared to CA in all patients, risk stratification with GXT was associated with a 15% reduction in cost. TEP for risk stratification was associated with a 23% reduction in cost compared to stratification only by GXT and a 48% reduction in cost compared to CA in all patients.

Conclusions:

Risk stratification using GXT and TEP is less costly than performing CA of the AP in all pediatric patients with asymptomatic ventricular pre-excitation.

Perspective:

Sudden death rarely is the first manifestation of the Wolff-Parkinson-White syndrome in individuals with asymptomatic ventricular pre-excitation. This being the case, the most cost-effective strategy may be to not perform any risk stratification testing and simply instruct patients to report the onset of symptoms of paroxysmal tachycardia, at which point CA of the AP could then be performed.

Clinical Topics: Arrhythmias and Clinical EP, Congenital Heart Disease and Pediatric Cardiology, EP Basic Science, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Congenital Heart Disease, CHD & Pediatrics and Arrhythmias

Keywords: Wolff-Parkinson-White Syndrome, Electrocardiography, Catheter Ablation, Exercise Test


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