Optimal reperfusion in NoS Malcolm Metcalfe

Optimum reperfusion Extensive data now available has lead to the formulation of guidelines essentially common to UK, Europe, North American and Antipodes. The crux of this are the major benefits which result from mechanical revascularisation (PPCI) as opposed to thrombolytic therapy. This advantage however is maximal within 90 minutes from diagnosis (ECG) to balloon inflation and probably non-existent greater than 120 minutes.

Lothian pilot Invaluable source of real world data Major logistic issue is transport Major logistic issue is transport Fixed front-end (15mins) and lab (35mins) times leaving maximum ambulance drive time of 40 mins Fixed front-end (15mins) and lab (35mins) times leaving maximum ambulance drive time of 40 mins Decision support system is essential Decision support system is essential Feedback to ambulance service important Feedback to ambulance service important Approximately 50% of AMIs occur in office hours Approximately 50% of AMIs occur in office hours

Isochrones

Other important considerations As many patients are outwith of a 40 minute drive time pre-hospital thrombolysis (PHT) is next best option 30% of these patients will not reperfuse and will require rescue PCI (Drip and ship). Inverness will only be office hours PCI centre from August Double jump admissions and A&E Departments are to be discouraged as they slow down this assessment and time to rescue with attendant increased mortality/morbidity.

Proposed rules of engagement Islands Drip and Ship with immediate air transport to Aberdeen. Drip and Ship with immediate air transport to Aberdeen.Highland After August patients within 40 min drivetime (inc W Moray) and within office hours to be taken to Raigmore for PPCI After August patients within 40 min drivetime (inc W Moray) and within office hours to be taken to Raigmore for PPCI Other patients to be given PHT and those which require rescue to be done locally (office hours) or immediate air transport to Aberdeen. Other patients to be given PHT and those which require rescue to be done locally (office hours) or immediate air transport to Aberdeen. This to be coordinated by local decision support service This to be coordinated by local decision support service Wick, Fort William and Skye probably hybrid of above coordinated by decision support service Wick, Fort William and Skye probably hybrid of above coordinated by decision support service

Proposed rules of engagement Grampian Office hours PPCI currently available with 24/7 emergency service available. Office hours PPCI currently available with 24/7 emergency service available. Plans to extent this to 24/7 later this year. Plans to extent this to 24/7 later this year. Other Grampian patients to be given PHT and shipped to Aberdeen. Other Grampian patients to be given PHT and shipped to Aberdeen. STEMI patients should bypass Dr Grays and all other community hospitals STEMI patients should bypass Dr Grays and all other community hospitals

Proposed rules of engagement Tayside Office hours PPCI service currently available Office hours PPCI service currently available BC acceptance to extend service to 24/7 from April BC acceptance to extend service to 24/7 from April May include N Fife too May include N Fife too Unusual population as majority live within 40 mins of Ninewells. Unusual population as majority live within 40 mins of Ninewells. Decision support will still direct to PHT with transfer to Ninewells as appropriate. Decision support will still direct to PHT with transfer to Ninewells as appropriate.

Discussion… So how do we make this all work?

Transcatheter aortic valve implantation (TAVI) Malcolm Metcalfe

TAVI Potentially life-saving therapy for patients unsuitable for conventional aortic valve replacement. No longer regarded as experimental At the end of 2009 c 8000 valves were implanted world- wide. 2 major competitors Medtronic Core-Valve Medtronic Core-Valve Edwards Sapien Edwards Sapien 3 methods of implantation Trans-arterially Trans-arterially Trans-apically Trans-apically Subclavian approach Subclavian approach

Surgical intervention should be performed promptly once even … minor symptoms occur 1 Surgical intervention should be performed promptly once even … minor symptoms occur 1 Chart: Ross J Jr, Braunwald E. Aortic stenosis. Circulation 1968;38 (Suppl 1) 1 C.M. Otto. Valve Disease: Timing of Aortic Valve Surgery. Heart 2000 Chart:: Ross J Jr, Braunwald E. Aortic stenosis. Circulation. 1968;38 (Suppl 1): Valvular Aortic Stenosis in Adults (Average Course)

Mortality in Aortic Valve Replacement Burr et al, Annals Thor Surg, 1995;60:S n = 1.984

Calculated numbers Probably 1000 for UK as a whole c100 for Scotland = 16 per million of population

What is the risk? Initial mortality approximately 10% Improving Core valve May 2008: 30 day mortality = 8% in first 1000 European implants Core valve May 2008: 30 day mortality = 8% in first 1000 European implants Edwards May 2009: 30 day mortality = 6.3% for TAVI and 10.3% for trans-apical in 1038 patients. Edwards May 2009: 30 day mortality = 6.3% for TAVI and 10.3% for trans-apical in 1038 patients.

Risks and benefits 3 year experience (Vancouver data to be published in Circulation) 168 patients, mean age patients, mean age 84. TAVI = 113 TAVI = 113 Trans-apical = 55 Trans-apical = 55 Major complications Transfusion 11.5% Transfusion 11.5% Major vascular surgery 6.6% Major vascular surgery 6.6% Pacemaker 5.4% Pacemaker 5.4% Renal failure 6% Renal failure 6% Pneumonia 4.8% Pneumonia 4.8% 30 days 14.9% 30 days 14.9%

Risks and benefits – Vancouver experience Mortalityp value Transarterially overall8.0% st half12.3% 2 nd half3.6% Transapically overall18.2% st half25% 2 nd half11.1%

Risks and benefits – Vancouver experience Benefits were sustained All NYHA class 3 & 4 patients improved by 1 class. All NYHA class 3 & 4 patients improved by 1 class. At 1 year 75% still alive (99) of which 77 were in class 1 or 2. At 1 year 75% still alive (99) of which 77 were in class 1 or 2.

Centres All 3 Scottish cardiothoracic centres could be capable of undertaking these procedures. Stringent criteria laid down as per formal commissioning framework (DH 3/09) Centres must undertake implants in first year and maintain this. At 16 per million population = pa for Scotland Initial rate may be less Expensive, 50% more than conventional AVR Thus need to decide how to deliver service

Genie is now out of the bottle – how to progress service All UK Cardiologists and Cardio-Thoracic surgeons are united in their support for this technology. Scotland lags far behind England, Wales, Other European countries and North America. Many referrals have already been made to English centres with good short-term results It would be regarded as morally indefensible by clinicians to try and stop this service Clinicians who do not offer this option could be subject to legal action. Its relatively expensive but compare, for example, to new cancer drugs It is no longer experimental but longer-term results are not well described and waters are being muddied by proposals to swop conventional high risk patients to TAVI (unproven, not costed and not licensed).