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Updated: Apr 23, 2026
Catheter Ablation in Combination With Left Atrial Appendage Closure for Atrial Fibrillation
Published on: February 26, 2013
Identifying future research priorities using value of information analyses: left atrial appendage occlusion devices
Andrew Micieli1, Maria C Bennell2, Ba' Pham3
1Faculty of Medicine, University of Ottawa, Ontario, Canada (A.M.).
Insights
Left atrial appendage occlusion devices are cost-effective for stroke prevention in atrial fibrillation. Further research is needed to clarify stroke reduction efficacy compared to warfarin, which remains a key area of uncertainty.
Area of Science:
- Cardiology
- Health Economics
- Decision Science
Background:
- Atrial fibrillation poses a significant stroke risk.
- Left atrial appendage occlusion (LAAO) devices offer an alternative to anticoagulants for stroke prophylaxis.
- Value-of-information analyses can guide research priorities by quantifying decisional uncertainty.
Purpose of the Study:
- To quantify decisional uncertainty surrounding the cost-effectiveness of LAAO devices versus anticoagulants (dabigatran, warfarin) for stroke prophylaxis in atrial fibrillation.
- To identify key parameters driving uncertainty and inform future research priorities.
Main Methods:
- A microsimulation decision-analytic model was employed.
- Probabilistic sensitivity analysis quantified parameter uncertainty.
- Expected value of perfect information (EVPI) and expected value of partial perfect information (EVPPI) analyses were conducted.
Main Results:
- Substantial uncertainty exists, with LAAO devices preferred in only 47% of simulations.
- The overall EVPI was $8542 per patient, indicating significant potential value in reducing uncertainty.
- The primary source of uncertainty stemmed from probability parameters, particularly the odds ratio for stroke with LAAO versus warfarin (EVPPI = $7312 per patient).
Conclusions:
- The relative efficacy of LAAO devices compared to warfarin for stroke reduction is a critical area of uncertainty.
- Future research should prioritize improving estimates for this parameter to enhance clinical decision-making.
Background:
Left atrial appendage occlusion devices are cost effective for stroke prophylaxis in atrial fibrillation when compared with dabigatran or warfarin. We illustrate the use of value-of-information analyses to quantify the degree and consequences of decisional uncertainty and to identify future research priorities.
Methods And Results:
A microsimulation decision-analytic model compared left atrial appendage occlusion devices to dabigatran or warfarin in atrial fibrillation. Probabilistic sensitivity analysis quantified the degree of parameter uncertainty. Expected value of perfect information analyses showed the consequences of this uncertainty. Expected value of partial perfect information analyses were done on sets of input parameters (cost, utilities, and probabilities) to identify the source of the greatest uncertainty. One-way sensitivity analyses identified individual parameters for expected value of partial perfect information analyses. Population expected value of perfect information and expected value of partial perfect information provided an upper bound on the cost of future research. Substantial uncertainty was identified, with left atrial appendage occlusion devices being preferred in only 47% of simulations. The expected value of perfect information was $8542 per patient and $227.3 million at a population level. The expected value of partial perfect information for the set of probability parameters represented the most important source of uncertainty, at $6875. Identified in 1-way sensitivity analyses, the expected value of partial perfect information for the odds ratio for stroke with left atrial appendage occlusion compared with warfarin was calculated at $7312 per patient or $194.5 million at a population level.
Conclusion:
The relative efficacy of stroke reduction with left atrial appendage occlusion devices in relation to warfarin is an important source of uncertainty. Improving estimates of this parameter should be the priority for future research in this area.
