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OBJECTIVES: The objective of this study was to evaluate the cost-effectiveness of quadripolar versus bipolar cardiac resynchronization defibrillator therapy systems. BACKGROUND: Quadripolar left ventricular (LV) leads for cardiac resynchronization therapy reduce phrenic nerve stimulation (PNS) and are associated with reduced mortality compared with bipolar leads. METHODS: A total of 606 patients received implants at 3 UK centers (319 Q, 287 B), between 2009 and 2014; mean follow-up was 879 days. Rehospitalization episodes were costed at National Health Service national tariff rates, and EQ-5D utility values were applied to heart failure admissions, acute coronary syndrome events, and mortality data, which were used to estimate quality-adjusted life-year differences over 5 years. RESULTS: Groups were matched with regard to age and sex. Patients with quadripolar implants had a lower rate of hospitalization than those with bipolar implants (42.6% vs. 55.4%; p = 0.002). This was primarily driven by fewer hospital readmissions for heart failure (51 [16%] vs. 75 [26.1%], respectively, for quadripolar vs. bipolar implants; p = 0.003) and generator replacements (9 [2.8%] vs. 19 [6.6%], respectively; p = 0.03). Hospitalization for suspected acute coronary syndrome, arrhythmia, device explantation, and lead revisions were similar. This lower health-care utilization cost translated into a cumulative 5-year cost saving for patients with quadripolar systems where the acquisition cost was <£932 (US $1,398) compared with bipolar systems. Probabilistic sensitivity analysis results mirrored the deterministic calculations. For the average additional price of £1,200 (US $1,800) over a bipolar system, the incremental cost-effective ratio was £3,692 per quality-adjusted life-year gained (US $5,538), far below the usual willingness-to-pay threshold of £20,000 (US $30,000). CONCLUSIONS: In a UK health-care 5-year time horizon, the additional purchase price of quadripolar cardiac resynchronization defibrillator therapy systems is largely offset by lower subsequent event costs up to 5 years after implantation, which makes this technology highly cost-effective compared with bipolar systems.

Original publication




Journal article


JACC Clin Electrophysiol

Publication Date





107 - 116


ACS, acute coronary syndrome, CRT, cardiac resynchronization therapy, CRTD, cardiac resynchronization defibrillator therapy device, HF, heart failure, ICER, incremental cost-effectiveness ratio, LV, left ventricular, NHS, National Health Service, NICE, National Institute for Health and Care Excellence, PNS, phrenic nerve stimulation, QALY, quality-adjusted life-year, cardiac resynchronization therapy, cost-effectiveness, implantable cardiac defibrillator, left ventricular pacing, quadripolar lead, Acute Coronary Syndrome, Aged, Arrhythmias, Cardiac, Cardiac Pacing, Artificial, Cardiac Resynchronization Therapy, Cardiac Resynchronization Therapy Devices, Cost-Benefit Analysis, Defibrillators, Implantable, Female, Heart Failure, Hospitalization, Humans, Male, Prosthesis Design, Quality-Adjusted Life Years, Registries, United Kingdom