BACKGROUND:Titanium hypersensitivity is a rare but important cause of recurrent complications in patients with cardiac implantable electronic devices (CIEDs). Despite titanium's biocompatibility, hypersensitivity reactions can mimic device infection, leading to repeated device removals before diagnosis. CASE PRESENTATION:We report the management of a 67-year-old man with non-ischemic cardiomyopathy who presented to our institution after three failed cardiac resynchronization therapy with defibrillator (CRT-D) implantations over three years, each complicated by wound dehiscence and infection-like symptoms. The patient had been diagnosed with titanium hypersensitivity previously but prior attempts to mitigate exposure, including a Gore-Tex-wrapped device were unsuccessful. Therefore, a custom gold-plated CRT-D was obtained under U.S. Food and Drug Administration (FDA) compassionate use provisions. The gold-plated CRT-D was implanted via a right-sided approach. At one-year follow-up, the surgical site remained well-healed with no recurrent complications or device-related discomfort and left ventricular ejection fraction (LVEF) improved from 29% to 50%. CONCLUSIONS:This case underscores the diagnostic challenges of titanium allergy, the limitations of conventional management, and the value of multidisciplinary collaboration to navigate regulatory pathways and deliver durable, patient-specific solutions.

In a nationwide examination of commercial prices for transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR), we observed substantial markups and variability across hospitals, payers, and plan types-including differences exceeding $90,000 among insurers. Higher prices did not consistently correlate with better clinical outcomes, suggesting that factors beyond quality of care drive these pricing differences. These findings underscore the need for greater transparency and further investigation into how pricing structures and market forces affect both cost and quality of care.

Background: The 2021 Price Transparency Final Rule required hospitals to publicly disclose commercial prices for all medical services. Using data made available by this legislation, we investigated variation in inpatient prices for percutaneous coronary intervention (PCI). Hypothesis: We hypothesized that there would be substantial differences in commercial prices between and within hospitals and that this variation would be associated with factors such as market competitiveness rather than patient outcomes. Methods: PCI hospitalization prices (MS-DRG 247-251) were obtained from Turquoise Health and linked to hospital characteristics. The association between price and hospital factors such as the Herfindahl–Hirschman index (HHI) for market competitiveness was evaluated using linear models. We also included hospital acute myocardial infarction (AMI) specific mortality and readmission rates made publicly available by Medicare. Results: Median commercial prices (N = 523 hospitals) were 1.7-1.9x higher than Medicare rates (Fig 1A). Self-pay prices were 2.4-3.0x higher. There was strong price correlation across DRG codes (Fig 1B). Across hospitals, the 90th percentile price was >2.5x the 10th percentile price. Within hospitals, the 90th percentile price was 1.7-2.1x the 10th percentile price. Prices varied greatly by region, with the Pacific being the most expensive and Midwest the least. For PCI with drug-eluting stents (DRG 246-247), teaching hospitals had higher prices than non-teaching hospitals (95% CI: +$4,000-5,000) whereas investor-owned hospitals had lower prices (95% CI: -$6,000-$9,000). Higher prices were not linked to hospital readmission and mortality statistics for AMI. On a system level, less competitive markets had significantly higher markups over Medicare rates (Fig 1C). Conclusion: Prices for PCI hospitalization vary significantly within and between hospitals and appear associated with hospital and system-level characteristics.

Background: Transcatheter aortic valve replacement (TAVR) is a crucial procedure for managing aortic stenosis (AS). Despite its widespread adoption, substantial price differences exist between hospitals and insurance companies. This study aims to analyze these variations across major insurers using new pricing data. Hypothesis: We hypothesize significant variation in TAVR prices across insurance plans, influenced by plan type and hospital characteristics. Methods: TAVR prices for Diagnosis Related Group (DRG) code 267 (TAVR without major cardiac complications) were analyzed using the Turquoise Health database. Prices from Aetna, Blue Cross Blue Shield, Cigna, Humana, Medicare, and United Healthcare were compared across HMO/Managed Care, Medicare Advantage, Medicaid, and Other plan types. Outliers beyond the 95th and below the 5th percentiles were excluded. Results: The median commercial price for TAVR was $71,312, about 1.88 times the Medicare rate. In comparison, the median cash price was $78,000. List prices were the highest, with a median of $166,714 and a substantial standard deviation of $83,534. Price variation between hospitals (2.6 times) was greater than within hospitals (2.0 times). Geographic differences significantly influenced prices, with median TAVR prices ranging from $54,915 in New England to $105,538 in the Pacific region (Fig 1A). Aetna had the highest median TAVR price at $84,190, with a standard deviation of $53,186. Medicare had the lowest median price at $37,865 and the least variability, with a standard deviation of $7,566. HMO/Managed Care plans showed the highest prices and variability, with an average median price of $78,725 and a standard deviation of $54,082 (Fig 1B). Medicare Advantage plans had substantially lower rates, with an average median price of $38,044 and a standard deviation of $14,890. Conclusion: This study highlights substantial TAVR price variation across major insurers and plan types. Aetna had the highest prices and variability, particularly in HMO/Managed Care plans, while Medicare Advantage plans had lower prices and variability compared to HMO/Managed Care plans. These findings emphasize the need for greater transparency and standardization in TAVR pricing to reduce disparities and control healthcare costs.

Heart failure (HF) poses a significant economic burden in the US, with costs projected to reach $70 billion by 2030. Cost-effectiveness analyses play a pivotal role in assessing the economic value of HF therapies. In this review, we overview the cost-effectiveness of HF therapies and discuss ways to improve patient access. Based on current costs, guideline directed medical therapies for HF with reduced ejection fraction provide high economic value except for sodium-glucose cotransporter-2 inhibitors, which provide intermediate economic value. Combining therapy with the four pillars of medical therapy also has intermediate economic value, with incremental cost-effectiveness ratios ranging from $73,000 to $98,500/ quality adjusted life-years. High economic value procedures include cardiac resynchronization devices, implantable cardioverter-defibrillators, and coronary artery bypass surgery. In contrast, advanced HF therapies have previously demonstrated intermediate to low economic value, but newer data appear more favorable. Given the affordability challenges of HF therapies, additional efforts are needed to ensure optimal care for patients. The recent Inflation Reduction Act contains provisions to reform policy pertaining to drug price negotiation and out-of-pocket spending, as well as measures to increase access to existing programs, including the Medicare low-income subsidy. On a patient level, it is also important to encourage patient and physician awareness and discussions surrounding medical costs. Overall, a broad approach to improving available therapies and access to care is needed to reduce the growing clinical and economic morbidity of HF.

Background Little is known about hospital pricing for coronary artery bypass grafting (CABG). Using new price transparency data, we assessed variation in CABG prices across US hospitals and the association between higher prices and hospital characteristics, including quality of care. Methods and Results Prices for diagnosis related group code 236 were obtained from the Turquoise database and linked by Medicare Facility ID to publicly available hospital characteristics. Univariate and multivariable analyses were performed to assess factors predictive of higher prices. Across 544 hospitals, median commercial and self‐pay rates were 2.01 and 2.64 times the Medicare rate ($57 240 and $75 047, respectively, versus $28 398). Within hospitals, the 90th percentile insurer‐negotiated price was 1.83 times the 10th percentile price. Across hospitals, the 90th percentile commercial rate was 2.91 times the 10th percentile hospital rate. Regional median hospital prices ranged from $35 624 in the East South Central to $84 080 in the Pacific. In univariate analysis, higher inpatient revenue, greater annual discharges, and major teaching status were significantly associated with higher prices. In multivariable analysis, major teaching and investor‐owned status were associated with significantly higher prices (+$8653 and +$12 200, respectively). CABG prices were not related to death, readmissions, patient ratings, or overall Centers for Medicare and Medicaid Services hospital rating. Conclusions There is significant variation in CABG pricing, with certain characteristics associated with higher rates, including major teaching status and investor ownership. Notably, higher CABG prices were not associated with better‐quality care, suggesting a need for further investigation into drivers of pricing variation and the implications for health care spending and access.

Background: While transthoracic echocardiography (TTE) is responsible for more Medicare spending than any other cardiovascular imaging procedure, little is known about its commercial cost footprint. The 2021 Hospital Price Transparency Final Rule mandated that U.S. hospitals publish their insurer-negotiated and self-pay pri-ces for services. This study sought to characterize and assess factors contributing to variation in TTE prices. Methods: We used a commercial database containing hospital-disclosed prices to characterize variation in TTE prices within and across hospitals. We linked these price data to hospital and regional characteristics using Medicare Facility IDs. Results: A total of 1,949 hospitals reported commercial prices. Among reporting hospitals, median commercial and self-pay prices were 2.93 and 3.06 times greater than the median Medicare price ($1,313 and $1,422, respectively, vs $464). Within hospitals, the 90th percentile payer-negotiated rate was 2.78 (interquartile range, 1.80-5.09) times the 10th percentile rate (within-center ratio). Across hospitals within the same hospital referral region, the median price at the 90th percentile hospital was 2.47 (interquartile range, 1.69-3.75) times that at the 10th percentile hospital (across-center ratio). On univariate analysis, for-profit (P = .04), teaching (P < .01), investor-owned (P < .01), and higher-rated hospitals (P < .01) charged higher prices, whereas rural referral centers (P = .01) and disproportionate share hospitals (P < .01) charged less. On multivariate analysis, the association between these characteristics and TTE prices persisted, except for investor ownership and rural referral centers. Conclusions: Self-pay and commercial TTE prices were higher than Medicare prices and varied significantly within and across hospitals. For-profit, teaching, and higher-rated hospitals had higher prices, in contrast to DSH hospitals. A better understanding of the relationship between this cost variation and quality of care is critical given the impact of cost on health care access and affordability. (J Am Soc Echocardiogr 2023;36:569-77.)

Introduction Transcatheter Aortic Valve Replacement (TAVR) has become a mainstay of aortic stenosis treatment, alongside Surgical Aortic Valve Replacement (SAVR). Despite their widespread use, little is known about their commercial cost burden as this data was confidential prior to the 2021 Federal Price Transparency Final Rule. Using newly available pricing data, we aimed to compare hospital variation in TAVR and SAVR prices and describe factors predictive of prices. Methods Prices for DRG 267 (TAVR) and 220 (SAVR) were extracted from the Turquoise Health database and linked to hospital characteristics using Medicare IDs. Price variation within and across hospitals was assessed by calculating the ratio between the 90th and 10th percentile commercial or hospital rates, respectively. The Kruskal-Wallis test was used to test for associations between price and categorical factors. Results 1116 hospitals reported prices for TAVR and 1215 hospitals reported prices for SAVR. Commercial prices for TAVR ($70,482) and SAVR ($66,629) were 1.83 and 1.77x the Medicare price. Within hospitals, the 90th percentile payer-negotiated TAVR price was 1.80x the 10th percentile price, while across hospitals, the 90th percentile hospital by median commercial price was 3.40x the 10th percentile price. This was similar for SAVR. Several factors were associated with higher prices, including major teaching status (TAVR $17,736 and SAVR $19,057 vs non-teaching). For-profit status and investor-ownership were associated with lower prices. While higher hospital-wide readmission rates and higher hospital ratings were associated with higher prices, there was no significant association with hospital-wide mortality. Conclusion This analysis demonstrates substantial markups for TAVR and SAVR commercial prices and significant variation both within and between hospitals associated with teaching status, hospital ratings, and readmissions but not hospital mortality.

Gastroesophageal reflux is increasingly treated with LINX®, a flexible bracelet of magnetic titanium beads (not MRI compatible) that is laparoscopically implanted to wrap around the gastroesophageal junction for providing tone/support aiding passive relaxation of a weak lower esophageal sphincter with peristalsis. The FDA currently cautions against concurrent use of the LINX® system with cardiac implantable electronic devices (CIEDs) given that the risk of electromagnetic interference (EMI) is unknown, and safety has not been established.

Ablation of atrial fibrillation (AF) and ventricular tachycardia (VT) comprise a significant proportion of catheter ablation procedures. However, few studies have explored the commercial cost footprint of these procedures, despite the 2021 Hospital Price Transparency Final Rule mandating US hospitals publish their insurer-negotiated prices.

Since their approval in the US in 2015, left atrial appendage closure (LAAC) devices have served as an alternative to oral anticoagulation in atrial fibrillation (AF) patients at increased risk of bleeding. However, few studies have explored the commercial cost footprint of LAAC procedures, despite the 2021 Hospital Price Transparency Final Rule mandating US hospitals publish their insurer-negotiated prices.

Introduction: Transthoracic echocardiography (TTE) is widely used in clinical practice. Medicare pays over $900 million annually for TTE. Using hospital-reported data, we sought to characterize variation in payer-negotiated (commercial) and self-pay prices for TTE within and across hospitals in the US. Methods: As of January 2021, federal price transparency legislation began requiring hospitals to publish chargemaster, discounted self-pay and commercial prices for all hospital services. We used the Turquoise Health database to gather this price data for TTE based on common procedural terminology (CPT) code 93306. Results: A total of 1,949 hospitals nationwide reported commercial prices for CPT 93306. Raw median prices varied widely across the US [$1398 (IQR $1064-$1661)] (Figure A). The median number of commercial plans per hospital was 20 (IQR 8-42) (Figure B). Compared with a median Medicare price of $464 (IQR $445-$493), the median commercial and discounted self-pay prices were $1313 (IQR $744-$1948) and $1422 (IQR $836-$2189) respectively, representing a 2.83- and 3.06-fold markup from the Medicare rate. The median chargemaster price was $2497 (IQR $1731-$3576), corresponding to a 5.38-fold markup. Within hospitals, the 90th percentile payer-negotiated rate was 2.78 (IQR 1.80-5.09) times the 10th percentile price (within-center ratio). Across hospitals within the same hospital referral region (HRR), the median price at the 90th percentile hospital was 2.47 (IQR 1.69-3.75) times that at the 10th percentile hospital (across-center ratio). Conclusions: Self-pay and commercial TTE prices are substantially higher than Medicare prices. There is significant variation in payer-negotiated rates within and across hospitals. More research is needed to understand the factors leading to this price variation and its relation to quality of care and access amidst rising healthcare costs in the US.

OBJECTIVES This study aimed to determine the feasibility of using radioablation for arrhythmogenic a substrate modification. BACKGROUND Stereotactic body radiation therapy (SBRT) is a promising therapy for ventricular tachycardia (VT) refractory to catheter ablation. METHODS A total of 6 male patients (median age 72 years) with ischemic cardiomyopathy (left ventricular ejection fraction 20% [interquartile range (IQR): 16%-25%]) and VT refractory to antiarrhythmic medications and catheter ablations underwent SBRT to extensive scar substrate. In addition to electroanatomical mapping, 5 of 6 patients had computed tomography segmentation using MUSIC (IHU Liryc, Univ. Bordeaux and Inria Sophia Antipolis, France). Regions of wall thinning <5 mm, calcification, and intramyocardial fat were targeted for radioablation at 25 Gy. RESULTS The median planning target volume was 319 (IQR: 280-330) mL. Device-treated or sustained VT episodes were not significantly reduced by radioablation (median 42 [IQR: 19-269] to 29 [IQR: 0-81]; P = 0.438). However, a reduction in device shocks was observed from 12 (IQR: 3-19) to 0 (IQR: 0-1) (P = 0.046). Over a follow-up period of 231 (IQR: 212-311) days, 3 patients died of end-stage heart failure and 3 of 6 patients had possible adverse events (heart failure exacerbation, pneumonia, and an asymptomatic pericardial effusion). CONCLUSIONS Substrate modification using SBRT assisted by computed tomography segmentation is feasible for treatment of VT in patients with ischemic cardiomyopathy. Although a significant reduction in device shocks was observed, suboptimal VT burden reduction and significant mortality rate in this cohort of patients with advanced car-diomyopathy underscore the need to improve mechanistic understanding for antiarrhythmic effects to guide dosing and targeting of scar substrates. (J Am Coll Cardiol EP 2022;8:49-58) (c) 2022 by the American College of Cardiology Foundation.

Aims To compare the cost of cardiac stereotactic body radioablation therapy (SBRT) versus catheter ablation for treating ventricular tachycardia (VT). Background Cardiac SBRT is a novel way of treating refractory VT that may be less costly than catheter ablation, owing to its noninvasive, outpatient nature. However, the true costs of either procedure are not well described, which could help inform a more appropriate reimbursement for cardiac SBRT than simply cross-indexing existing procedural rates. Methods Process maps were derived for the full patient care cycle of both procedures using time-driven activity-based costing. Step-by-step timestamps were collected prospectively from a 10-patient SBRT cohort and retrospectively from a 59-patient catheter ablation cohort. Individual costs were estimated by multiplying timestamps with capacity cost rates (CCRs) for personnel, space, equipment, consumable, and indirect resources. These were summed into total cost, which for cardiac SBRT was compared with current catheter ablation and single-fraction lung SBRT reimbursements, both potential reference rates for cardiac SBRT. Results The direct and total procedural costs of cardiac SBRT ($7549 and $10,621) were 49% and 54% less than those of VT ablation ($14,707 and $23,225). These costs were significantly different from current reimbursement for catheter ablation ($22,692) and lung SBRT ($6329). After including hospitalization expenses (>=$15,000), VT ablation costs at least $27,604 more to furnish than cardiac SBRT. Conclusions Time-driven activity-based costing (TDABC) can be a helpful tool for assessing healthcare costs, including novel treatment approaches. In addition to its clinical benefits, cardiac SBRT may provide significant cost reduction opportunities for treatment of VT.

Background Tyrosine kinase inhibitors (TKIs) have been increasingly used as first-line therapy in hematologic and solid-organ malignancies. Multiple TKIs have been linked with the development of cardiovascular complications, especially atrial arrhythmias, but data on ventricular arrhythmias (VAs) is scarce. Methods Herein we describe five detailed cases of VAs related to TKI use in patients with varied baseline cardiovascular risk factors between 2019 and 2022 at three centers. Individual chart review was conducted retrospectively. Results Patient ages ranged from 43 to 83 years. Three patients were on Bruton's TKI (2 ibrutinib and 1 zanubrutinib) at the time of VAs; other TKIs involved were afatinib and dasatinib. Three patients had a high burden of non-sustained ventricular tachycardia (NSVT) requiring interventions, whereas two patients had sustained VAs. While all patients in our case series had significant improvement in VA burden after TKI cessation, two patients required new long-term antiarrhythmic drug therapy, and one had an implantable defibrillator cardioverter (ICD) placed due to persistent VAs after cessation of TKI therapy. One patient reinitiated TKI therapy after control of arrhythmia was achieved with antiarrhythmic drug therapy. Conclusions Given the expanding long-term use of TKIs among a growing population of cancer patients, it is critical to acknowledge the association of TKIs with cardiovascular complications such as VAs, to characterize those at risk, and deploy preventive and therapeutic measures to avoid such complications and interference with oncologic therapy. Further efforts are warranted to develop monitoring protocols and optimal treatment strategies for TKI-induced VAs.

INTRODUCTION:Despite advances in drug and catheter ablation therapy, long-term recurrence rates for ventricular tachycardia remain suboptimal. Cardiac stereotactic body radiotherapy (SBRT) is a novel treatment that has demonstrated reduction of arrhythmia episodes and favorable short-term safety profile in treatment-refractory patients. Nevertheless, the current clinical experience is early and limited. Recent studies have highlighted variable duration of treatment effect and substantial recurrence rates several months postradiation. Contributing to these differential outcomes are disparate approaches groups have taken in planning and delivering radiation, owing to both technical and knowledge gaps limiting optimization and standardization of cardiac SBRT.METHODS AND FINDINGS:In this report, we review the historical basis for cardiac SBRT and existing clinical data. We then elucidate the current technical gaps in cardiac radioablation, incorporating the current clinical experience, and summarize the ongoing and needed efforts to resolve them.CONCLUSION:Cardiac SBRT is an emerging therapy that holds promise for the treatment of ventricular tachycardia. Technical gaps remain, to be addressed by ongoing research and growing clincial experience.