O0009: Cost-effectiveness of Risk Assessing Asymptomatic Patients with Ventricular Pre-excitation

Background: Patients with ventricular pre-excitation (VPE), or asymptomatic WPW, can experience rapid electrical conduction down the accessory pathway (AP) during atrial fibrillation (AFib), resulting in ventricular fibrillation (VFib). The purpose of this study was to evaluate a cost-effective strategy that completes risk assessment of VPE patients by performing stepwise exercise stress test (EST)- transesophageal electrophysiology study (TEEPS)- transvenous electrophysiology study (TVEPS) until risk is determined (Group I) compared to immediate TVEPS (Group II).

Methods: Data analysis from published results on the use of EST and TEEPS performed at our institution between 2012-2021 on risk-stratifying patients with VPE. Cost-effectiveness analysis was performed with a decision tree model in TreeAge Pro 2022 comparing Group I to Group II. Cost data was extracted from non-facility limiting price Medicare reimbursements (Centers for Medicare and Medicaid Services). Low-risk ESTs were defined as those that had sudden loss of VPE without return during EST. Risk on TEEPS is defined as the shortest pre-excited RR interval (SPERRI) during AFib < 250msec. TEEPS was performed if the VPE persisted on the EST. If TEEPS had no risk or induced Afib with SPERRI > 250msec, no further testing was required. TVEPS was performed if TEEPS did not induce AFib, SPERRI < 250 msec, or the patient developed supraventricular tachycardia (SVT).

Results: Of patients with VPE who underwent EST, 22% (174/784) were deemed low-risk and needed no further testing; of patients who underwent TEEPS, 83% (30/36) were considered low risk and underwent no further testing. The stepwise approach involving EST, TEEPS and TVEPS when necessary for patients with asymptomatic VPE had an expected cost of $378.82 as compared to $692.25 for those who underwent TVEPS alone. This approach leads to an average savings of $313.43 per patient. In deterministic sensitivity analysis, this approach remains cost-effective as long as TEEPS efficacy rate is >25.0% on patients who are not deemed low-risk via EST.

Conclusion: Risk-assessing asymptomatic patients with VPE through stepwise EST, TEEPS, and TVEPS is more cost-effective than immediate TVEPS.