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
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Major logistic issue is transport
Fixed front-end (15mins) and lab (35mins)
times leaving maximum ambulance drive time
of 40 mins
Decision support system is essential
Feedback to ambulance service important
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
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Drip and Ship with immediate air transport to Aberdeen.
Highland
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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.
This to be coordinated by local decision support service
Wick, Fort William and Skye probably hybrid of above
coordinated by decision support service
Proposed rules of engagement
Grampian
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Office hours PPCI currently available with
24/7 emergency service available.
Plans to extent this to 24/7 later this year.
Other Grampian patients to be given PHT and
shipped to Aberdeen.
STEMI patients should bypass Dr Grays and
all other community hospitals
Proposed rules of engagement
Tayside
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Office hours PPCI service currently available
BC acceptance to extend service to 24/7 from
April
May include N Fife too
Unusual population as majority live within 40
mins of Ninewells.
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 worldwide.
2 major competitors
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Medtronic Core-Valve
Edwards Sapien
3 methods of implantation
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Trans-arterially
Trans-apically
Subclavian approach
Valvular Aortic Stenosis in Adults
(Average Course)
“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):617.
Mortality in Aortic Valve Replacement
n = 1.984
Burr et al, Annals Thor Surg, 1995;60:S264-269
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
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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.
Risks and benefits
3 year experience (Vancouver data to be
published in Circulation)
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168 patients, mean age 84.
TAVI = 113
Trans-apical = 55
Major complications
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Transfusion 11.5%
Major vascular surgery 6.6%
Pacemaker 5.4%
Renal failure 6%
Pneumonia 4.8%
MACCE @ 30 days 14.9%
Risks and benefits – Vancouver
experience
Mortality
p value
Transarterially
overall
1st half
2nd half
Transapically
overall
1st half
2nd half
8.0%
0.16
12.3%
3.6%
18.2%
25%
11.1%
0.30
Risks and benefits – Vancouver
experience
Benefits were sustained
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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.
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 25-50 implants in first
year and maintain this.
At 16 per million population = 90-100 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).