Author + information
- 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
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 JACCby 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.
- American College of Cardiology Foundation
- Wilkoff B.L.,
- DAVID Trial Investigators
- Goldberger Z.,
- Elbel B.,
- McPherson C.A.,
- Paltiel A.D.,
- Lampert R.
- Blisard D.,
- Rosenfeld J.C.,
- Estrada F.,
- Reed J.F. 3rd.