Radiofrequency catheter ablation of supraventricular tachycardia in children and adolescents : feasibility and cost-effectiveness in a low-income country.

The objective of this study is to provide results and costs of catheter ablation in children and adolescents in a low-income country. Reports from first-world countries have demonstrated the cost-effectiveness of radiofrequency catheter ablation (RFCA) compared to medical treatment of supraventricular tachycardia (SVT). The study included 28 patients younger than 18 years of age with SVT in a pediatric cardiology unit in Guatemala. All patients underwent RFCA. Clinical outcome and cost-effectiveness of RFCA compared to continued medical treatment were the end points. Twenty-four patients had successful ablation (85.7%). Mean age at RFCA was 11.42 +/- 3.49 years. Three patients underwent a second ablation, increasing the success rate to 96.4%. One remaining patient is awaiting a second procedure. At a mean follow-up of 13.69 +/- 7.16 months, all 27 patients who had a successful ablation remained in sinus rhythm. Mean cost per procedure was 4.9 times higher than that of medical treatment. However, the estimated cost of catheter ablation equal that of medical therapy after 5.1 years and is 3.4 times less after 20 years. Radiofrequency catheter ablation of SVT in children and adolescents is safe and cost-effective compared to medical therapy. Resources must be judiciously allocated, especially in low-income countries, to treat the largest number of pediatric patients.

Pharmacologic prophylaxis for postoperative atrial tachyarrhythmia in general thoracic surgery: evidence from randomized clinical trials.

BACKGROUND: Atrial tachyarrhythmia is the most common complication after general thoracic surgery and is associated with significant morbidity, longer hospital stay, and higher costs. We sought to determine whether the use of antiarrhythmic medications is associated with a reduced rate of postoperative atrial tachyarrhythmia. METHODS: MEDLINE, EMBASE, Cochrane Database of clinical trials (1980-2003), and reference lists of relevant articles were searched for randomized controlled trials with placebo control, general thoracic patients, and noncombined and prophylactic use of the medications. Search, data abstraction, and analyses were performed and confirmed by at least 2 authors. A fixed-effects model was used to perform meta-analyses. RESULTS: There were 11 unique trials (total n = 1294) that met the inclusion criteria. Calcium-channel blockers and beta-blockers reduced the risk of atrial tachyarrhythmia in 4 and 2 trials, respectively (relative risk of 0.50 and 95% confidence interval of 0.34-0.73; relative risk of 0.40 and 95% confidence interval of 0.17-0.95, respectively). However, beta-blockers tended to increase the risk of pulmonary edema (relative risk, 2.15; 95% confidence interval, 0.74-6.23). Magnesium tested in one unblinded trial also reduced the risk of atrial tachyarrhythmia (relative risk, 0.4; 95% confidence interval, 0.21-0.78). On the other hand, digitalis preparations were found to be harmful because they increased the risk of atrial tachyarrhythmia in 3 trials (relative risk, 1.51; 95% confidence interval, 1.00-2.28). Finally, 2 other medications, flecainide and amiodarone, were each tested in a single small trial, and their effects were associated with great uncertainty. CONCLUSIONS: Calcium-channel blockers and beta-blockers are effective in reducing postoperative atrial tachyarrhythmia. The use of these medications should be individualized, and possible adverse events of beta-blockers should be taken into account. Randomized clinical trials do not support the use of digitalis in general thoracic surgery. The value of magnesium as a supplement to a main prophylactic regimen should be explored.

Cardiac electrophysiology: a cost-effective approach.

Clinical cardiac electrophysiology is a relatively new discipline, heavily dependent upon new technology that is often expensive. In cardiac pacing, no effective alternative to permanent pacing usually exists for patients with Class I indications, so cost-reduction strategies involve appropriate selection and utilization of hardware and facilities. Cost-effective utilization of radiofrequency ablation and implantable cardioverter-defibrillators requires that these techniques be compared with alternative therapies, usually antiarrhythmic drugs. Both ablation and defibrillator implantation can be shown to be cost effective in selected populations, but a cost-conscious approach to procedures and patient selection can make them cost effective in a broad range of patients.