The higher initial cost of quadripolar left ventricular (LV) lead systems for cardiac resynchronization defibrillator therapy (CRT-D) can be offset by subsequent healthcare savings, according to a British study.
Cumulative costs at 5 years favored quadripolar systems that were up to $1,400 more expensive than bipolar ones, Jonathan M. Behar, MBBS, of St. Thomas’ Hospital in London, and colleagues reported in JACC: Clinical Electrophysiology.
The difference was at least partly because quadripolar LV lead recipients had fewer re-hospitalizations than the group getting bipolar leads (42.6% versus 55.4%, P=0.002), driven mostly by lower rates of heart failure readmission (16% versus 26.1%, P=0.003) and fewer generator replacements (2.8% versus 6.6%, P=0.03).
“The lower rates of hospitalization associated with a quadripolar lead in the current study may be driven by the improved efficacy in CRT delivery,” Behar and colleagues suggested, pointing to less phrenic nerve stimulation and fewer re-interventions for lead displacement.
Furthermore, “the presence of four poles on the quadripolar LV lead allows greater programmability and the ability to choose multiple vectors for CRT delivery. This provides the implanting physician with more choice for implant location that may allow leads to be implanted more distally in posterolateral or lateral veins for stability purposes, with the ability to stimulate the LV more basally from the proximal poles which in turn may contribute to more optimal CRT delivery resulting in less heart failure hospitalizations and reduced mortality.”
Behar’s group concluded that in the U.K., “the additional purchase price of quadripolar CRT-D systems is largely offset by lower subsequent event costs up to five years post implantation, making this technology highly cost effective compared with bipolar systems.”
The findings likely would generalize broadly to U.S. practice settings, cardiologists contacted by MedPage Today suggested.
“I implant these leads and I do believe the results, both in personal experience and from large-scale data,” Mintu Turakhia MD, MAS, of California’s Stanford University, said in an email. His group recently showed that quadripolar leads were associated with decreased risks of lead revision, lead inactivation, and death in a large observational study.
In the U.S., Turakhia emphasized, “the cost structure differences for the implanted devices as well as downstream complications will be different. So the exact numbers cannot be generalized, but U.S. data do show improved outcomes, which would suggest good value as long as cost differences are not extreme.”
And the cost differences appear less extreme than the $1,400 upper threshold for cost-effectiveness in Behar’s study. In the U.S., quadripolar leads are no more than $400 more expensive than bipolar leads, according to Alexandru Costea, MD, of the University of Cincinnati, who was not part of the study. “The cost between these leads is not that different, so we don’t necessarily have a concern that the quadripolar leads are going to add an excessive expense to the procedure,” he said in a telephone interview.
Behar’s study included 606 patients who got CRT-D at three centers from 2009 through 2014. The quadripolar and bipolar lead groups shared similar rates of hospitalization for suspected acute coronary syndrome, arrhythmia, device explant, and lead revision.
Quadripolar CRT-D systems that were $1,400 to $3,600 more expensive than bipolar alternatives were not more cost effective than those with bipolar leads but came out similar on 5-year costs.
Both Costea and Turakhia expressed a clear preference for quadripolar CRT-D leads. “I think they’re better and they give you more options for avoiding the phrenic nerve,” said Costea. Turakhia said “quadripolar leads are more forgiving with respect to location, allowing for a faster implant, less radiation exposure to the operators and staff, and more latitude in reprogramming to circumvent complications.”
Limitations of Behar’s cost analysis included lack of randomization and no modeling beyond the 5-year data.
Behar reported no relevant relationships with industry.
Costea reported past relationships with Biotronik, St. Jude Medical, and Medtronic.
Turakhia declared consulting for St. Jude Medical.
JACC: Clinical Electrophysiology
Behar JM, et al “A cost effectiveness analysis of quadripolar versus bipolar left ventricular leads for cardiac resynchronization defibrillator therapy in a large multi-centre UK registry” JACC Clin Electrophysiol 2016; DOI: 10.1016/j.jacep.2016.04.009.