Wearable cardioverter-defibrillators in pediatric cardiomyopathy: A cost-utility analysis

Published:August 30, 2019DOI:


      Dilated cardiomyopathy (DCM) is the most common cardiomyopathy in children. Patients with severe cardiac dysfunction are thought to be at risk of sudden cardiac arrest (SCA). After diagnosis, a period of medical optimization is recommended before permanent implantable cardioverter-defibrillator (ICD) implantation. Wearable cardioverter-defibrillators (WCDs) provide an option for arrhythmia protection as an outpatient during this optimization.


      The purpose of this study was to determine the strategy that optimizes cost and survival during medical optimization of a patient with DCM before ICD placement.


      A Markov state transition model was constructed for the 3 clinical approaches to compare costs, clinical outcomes, and quality of life: (1) “Inpatient,” (2) “Home-WCD,” and (3) “Home-No WCD.” Transitional probabilities, costs, and utility metrics were extracted from the existing literature. Cost-effectiveness was assessed comparing each paradigm’s incremental cost-effectiveness ratio against a societal willingness-to-pay threshold of $50,000 per quality-adjusted life year.


      The cost-utility analysis illustrated that Home-WCD met the willingness-to-pay threshold with an incremental cost-effectiveness ratio of $20,103 per quality-adjusted life year and 4 mortalities prevented per 100 patients as compared with Home-No WCD. One-way sensitivity analyses demonstrated that Home-No WCD became the most cost-effective solution when the probability of SCA fell below 0.2% per week, the probability of SCA survival with a WCD fell below 9.8%, or the probability of SCA survival with Home-No WCD quadrupled from base-case assumptions.


      Based on the existing literature probabilities of SCA in pediatric patients with DCM undergoing medical optimization before ICD implantation, sending a patient home with a WCD may be a cost-effective strategy.


      To read this article in full you will need to make a payment


      Subscribe to Heart Rhythm
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Towbin J.A.
        • Lowe A.M.
        • Colan S.D.
        • et al.
        Incidence, causes, and outcomes of dilated cardiomyopathy in children.
        JAMA. 2006; 296: 1867-1876
        • Epstein A.E.
        • Dimarco J.P.
        • Ellenbogen K.A.
        • et al.
        ACC/AHA/HRS 2008 guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: executive summary.
        Heart Rhythm. 2008; 5: 934-955
        • Russo A.M.
        • Stainback R.F.
        • Bailey S.R.
        • et al.
        ACCF/HRS/AHA/ASE/HFSA/SCAI/SCCT/SCMR 2013 appropriate use criteria for implantable cardioverter-defibrillators and cardiac resynchronization therapy: a report of the American College of Cardiology Foundation appropriate use criteria task force, Heart Rhythm Society, American Heart Association, American Society of Echocardiography, Heart Failure Society of America, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance.
        J Am Coll Cardiol. 2013; 61: 1318-1368
        • El-Assaad I.
        • Al-Kindi S.G.
        • Oliveira G.H.
        • Boyle G.J.
        • Aziz P.F.
        Implantable cardioverter-defibrillator and wait-list outcomes in pediatric patients awaiting heart transplantation.
        Heart Rhythm. 2015; 12: 2443-2448
        • Dimas V.V.
        • Denfield S.W.
        • Friedman R.A.
        • et al.
        Frequency of cardiac death in children with idiopathic dilated cardiomyopathy.
        Am J Cardiol. 2009; 104: 1574-1577
        • Dubin A.M.
        • Berul C.I.
        • Bevilacqua L.M.
        • et al.
        The use of implantable cardioverter-defibrillators in pediatric patients awaiting heart transplantation.
        J Card Fail. 2003; 9: 375-379
        • Feingold B.
        • Arora G.
        • Webber S.A.
        • Smith K.J.
        Cost-effectiveness of implantable cardioverter-defibrillators in children with dilated cardiomyopathy.
        J Card Fail. 2010; 16: 734-741
        • Feldman A.M.
        • Klein H.
        • Tchou P.
        • et al.
        Use of a wearable defibrillator in terminating tachyarrhythmias in patients at high risk for sudden death: results of the WEARIT/BIROAD.
        Pacing Clin Electrophysiol. 2004; 27: 4-9
        • Spar D.S.
        • Bianco N.R.
        • Knilans T.K.
        • Czosek R.J.
        • Anderson J.B.
        The US experience of the wearable cardioverter-defibrillator in pediatric patients.
        Circ Arrhythm Electrophysiol. 2018; 11: e006163
        • Everitt M.D.
        • Sleeper L.A.
        • Lu M.
        • et al.
        Recovery of echocardiographic function in children with idiopathic dilated cardiomyopathy: results from the Pediatric Cardiomyopathy Registry.
        J Am Coll Cardiol. 2014; 63: 1405-1413
        • Healy C.A.
        • Carrillo R.G.
        Wearable cardioverter-defibrillator for prevention of sudden cardiac death after infected implantable cardioverter-defibrillator removal: a cost-effectiveness evaluation.
        Heart Rhythm. 2015; 12: 1565-1573
        • Alten J.A.
        • Klugman D.
        • Raymond T.T.
        • et al.
        Epidemiology and outcomes of cardiac arrest in pediatric cardiac ICUs.
        Pediatr Crit Care Med. 2017; 18: 935-943
        • Czosek R.J.
        • Bonney W.J.
        • Cassedy A.
        • et al.
        Impact of cardiac devices on the quality of life in pediatric patients.
        Circ Arrhythm Electrophysiol. 2012; 5: 1064-1072
        • Singh R.K.
        • Canter C.E.
        • Shi L.
        • et al.
        Survival without cardiac transplantation among children with dilated cardiomyopathy.
        J Am Coll Cardiol. 2017; 70: 2663-2673
        • Dayton J.D.
        • Kanter K.R.
        • Vincent R.N.
        • Mahle W.T.
        Cost-effectiveness of pediatric heart transplantation.
        J Heart Lung Transplant. 2006; 25: 409-415
        • Neumann P.J.
        • Cohen J.T.
        • Weinstein M.C.
        Updating cost-effectiveness—the curious resilience of the $50,000-per-QALY threshold.
        N Engl J Med. 2014; : 796-797
        • Wilmot I.
        • Cephus C.E.
        • Cassedy A.
        • Kudel I.
        • Marino B.S.
        • Jefferies J.L.
        Health-related quality of life in children with heart failure as perceived by children and parents.
        Cardiol Young. 2016; 26: 885-893
        • Desai A.D.
        • Zhou C.
        • Stanford S.
        • Haaland W.
        • Varni J.W.
        • Mangione-Smith R.M.
        Validity and responsiveness of the Pediatric Quality of Life Inventory (PedsQL) 4.0 generic core scales in the pediatric inpatient setting.
        JAMA Pediatr. 2014; 168: 1114-1121
        • Czosek R.J.
        • Spar D.S.
        • Khoury P.R.
        • et al.
        Outcomes, arrhythmic burden and ambulatory monitoring of pediatric patients with left ventricular non-compaction and preserved left ventricular function.
        Am J Cardiol. 2015; 115: 962-966
        • Khan K.A.
        • Petrou S.
        • Rivero-Arias O.
        • Walters S.J.
        • Boyle S.E.
        Mapping EQ-5D utility scores from the PedsQL generic core scales.
        Pharmacoeconomics. 2014; 32: 693-706
        • Friedman R.A.
        • Moak J.P.
        • Garson Jr., A.
        Clinical course of idiopathic dilated cardiomyopathy in children.
        J Am Coll Cardiol. 1991; 18: 152-156
        • Pahl E.
        • Sleeper L.A.
        • Canter C.E.
        • et al.
        Incidence of and risk factors for sudden cardiac death in children with dilated cardiomyopathy: a report from the Pediatric Cardiomyopathy Registry.
        J Am Coll Cardiol. 2012; 59: 607-615