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Catheter ablation of atrial fibrillation (Afib) was cost effective compared with medical management alone, subanalysis of the CABANA trial showed.

The procedure cost $57,433 per quality-adjusted life-year (QALY) gained, which met the conventional $100,000 willingness-to-pay threshold, reported Derek Chew, MD, of the Duke Clinical Research Institute in Durham, North Carolina, at the hybrid Heart Rhythm Society (HRS) meeting, held online and in Boston.

Cost effectiveness was somewhat more compelling in the heart failure subgroup, with a cost of $54,321 per QALY gained.

Ablation looked "economically attractive" largely based on the quality-of-life gains, in addition to a mortality benefit in the heart failure group, Chew said at the late-breaking clinical trial session.

"The question of whether it is cost effective is very important as more and more patients are undergoing Afib ablation," commented HRS session study discussant Kimberly Selzman, MD, MPH, of the George E. Wahlen VA Hospital in Salt Lake City. It was reassuring, too, that cost effectiveness was in the range of the older $50,000 benchmark, she said.

When modeled over a lifetime, the ablation group did have somewhat higher costs, largely driven by the expense of the procedure, compared with those randomized to medication alone ($150,987 vs $135,594).

The mortality difference was projected at less than a month, but the trial did show a quality-of-life advantage to ablation that translated to a lifetime gain of 0.27 QALYs.

Among the 778 patients with heart failure at baseline, a group in which the main intent-to-treat trial results had shown a mortality benefit, the gain was a more substantial 0.53 life-years and 0.65 QALYs.

HRS session study discussant Mark Link, MD, of UT Southwestern Medical Center in Dallas, expressed surprise that the costs were so similar between groups and questioned whether crossovers were again to blame.

Out of CABANA's 2,204 patients, 9.2% of patients randomized to ablation didn't actually get the procedure and 27.5% of the drug group crossed over to ablation.

Because of that, the primary intent-to-treat analysis did not show a significant impact on the composite of death, disabling stroke, serious bleeding, or cardiac arrest (HR 0.86, P=0.303) or on all-cause mortality alone (HR 0.85, P=0.377). Per-protocol analysis showed a significant 33% relative reduction in the primary composite endpoint and 40% relative reduction in all-cause mortality.

The majority of the costs accrued in the first year of follow-up, centered on the cost of the procedure, Chew said. While crossovers did bring up the costs for the medical group over the lifetime modeling, the cost-effectiveness findings were robust to a variety of sensitivity analyses, he noted.

The analysis used age-based regression modeling, quality-of-life weights, and accounted for repeat ablation procedures. The analysis included inpatient costs collected directly in the trial as well as the cost of medications and outpatient care.

The trial included patients ages 65 and older (or younger with at least one stroke risk factor) treated in 10 countries for new onset or undertreated paroxysmal, persistent, or long-standing persistent Afib who were eligible for ablation and two or more rhythm or rate control drugs. Costs were predicted based on modeling for trial participants outside the U.S.

"It's important to continue to do these economic analyses as the technology for Afib ablation evolves and more and more patients undergo this therapy," Selzman urged.

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