CORRESPONDENCE: LETTER TO THE EDITOR
Cost Advantage of Different Cardioverter-Defibrillator Devices
George D. Veenhuyzen, MD, FRCPC*
* Libin Cardiovascular Institute of Alberta, University of Calgary, Foothills Hospital Room C836, 1403 29th Street NW, Calgary, AB, T2N 2T9, Canada (Email: george.veenhuyzen{at}calgaryhealthregion.ca).
Among patients without a bradycardia indication for pacing, the presumed benefits of routine dual- versus single-chamber implantable cardioverter-defibrillator (ICD) usage, including a potential reduction in inappropriate shocks by enhancement of supraventricular tachycardia detection, remain unproven (1). Adding to the list of soft reasons for routine dual-chamber device usage is the recent study in JACC by Goldberger et al. (2), who analyzed the financial costs associated with a strategy of universal dual-chamber ICD placement versus implantation of a single-chamber ICD followed by upgrade as clinically indicated. That analysis suggests that even with upgrade rates as low as 5%, a universal dual-chamber implant approach could be the most cost-effective. However, the analysis could not consider two costs, which, though not monetary, are of primary importance.
First, the addition of implanting an atrial lead is associated, not surprisingly, with at least a doubling of device and lead-related complication rates (3–5). This price would be paid by our patients directly should a universal dual-chamber implant approach be taken.
Second, there would be an unmeasurable price paid by our profession as a whole were we to abandon our ethical obligation to our individual patients by employing a strategy that asks them to shoulder the burden of unnecessary medical procedures in the interests of reducing "costs to the system." Surgeons accept performing 1 or 2 unnecessary appendectomies in 10 to minimize the chance of perforated appendicitis (6). Are we to accept performing more than 9 unnecessary procedures in 10 and placing more than 90% of our patients in (unnecessary) harm’s way to save some money? The clinical benefits that we might realistically expect our individual patients to experience from a universal dual- versus single-chamber implantation approach must first be established before any cost analysis such as this one should have any influence on ethical practice.
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1. Wilkoff BL, DAVID Trial Investigators The Dual chamber And VVI Implantable Defibrillator (DAVID) trialrationale, design, results, clinical implications and lessons for future trials. Card Electrophysiol Rev 2003;4:468-472.2. Goldberger Z, Elbel B, McPherson CA, Paltiel AD, Lampert R. Cost advantage of dual-chamber versus single-chamber cardioverter-defibrillator implantation J Am Coll Cardiol 2005;46:850-857.[Abstract/Free Full Text] 3. Toff WD, Camm JA, Skehan JD, United Kingdom Pacing and Cardiovascular Events (UKPACE) Trial Investigators Single-chamber versus dual-chamber pacing for high-grade atrioventricular block N Engl J Med 2005;353:145-155.[Abstract/Free Full Text] 4. Connolly SJ, Kerr C, Gent M, et al. Effects of physiologic pacing versus ventricular pacing on the risk of stroke and death due to cardiovascular causes N Engl J Med 2000;342:1385-1391.[Abstract/Free Full Text] 5. Takahashi T, Bhandari AK, Watanuki M, Cannom DS, Sakurada H, Hiraoka M. High incidence of device-related and lead-related complications in the dual-chamber implantable cardioverter defibrillator compared with the single-chamber version Circ J 2002;66:746-750.[CrossRef][Web of Science][Medline] 6. Blisard D, Rosenfeld JC, Estrada F, Reed 3rd JF. Institutioning a clinical practice guideline to decrease the rate of normal appendectomies Am Surg 2003;699:796-798.
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