optimal reperfusion in nos

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Optimal Optimal reperfusion in NoS reperfusion in NoS Malcolm Metcalfe Malcolm Metcalfe

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Optimal reperfusion in NoS. Malcolm Metcalfe. Extensive data now available has lead to the formulation of guidelines essentially common to UK, Europe, North American and Antipodes. - PowerPoint PPT Presentation

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Page 1: Optimal reperfusion in NoS

Optimal reperfusion in Optimal reperfusion in NoSNoS

Malcolm MetcalfeMalcolm Metcalfe

Page 2: Optimal reperfusion in NoS

Optimum reperfusionOptimum reperfusion

Extensive data now available has lead to the Extensive data now available has lead to the formulation of guidelines essentially common to formulation of guidelines essentially common to UK, Europe, North American and Antipodes.UK, Europe, North American and Antipodes.

The crux of this are the major benefits which The crux of this are the major benefits which result from mechanical revascularisation (PPCI) result from mechanical revascularisation (PPCI) as opposed to thrombolytic therapy.as opposed to thrombolytic therapy.

This advantage however is maximal within 90 This advantage however is maximal within 90 minutes from diagnosis (ECG) to balloon minutes from diagnosis (ECG) to balloon inflation and probably non-existent greater than inflation and probably non-existent greater than 120 minutes. 120 minutes.

Page 3: Optimal reperfusion in NoS
Page 4: Optimal reperfusion in NoS

Lothian pilotLothian pilot

Invaluable source of real world dataInvaluable source of real world data Major logistic issue is transportMajor logistic issue is transport Fixed front-end (15mins) and lab (35mins) Fixed front-end (15mins) and lab (35mins)

times leaving maximum ambulance drive time times leaving maximum ambulance drive time of 40 minsof 40 mins

Decision support system is essentialDecision support system is essential Feedback to ambulance service importantFeedback to ambulance service important Approximately 50% of AMIs occur in “office Approximately 50% of AMIs occur in “office

hours”hours”

Page 5: Optimal reperfusion in NoS

IsochronesIsochrones

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Other important considerationsOther important considerations

As many patients are outwith of a 40 minute As many patients are outwith of a 40 minute drive time pre-hospital thrombolysis (PHT) is drive time pre-hospital thrombolysis (PHT) is next best optionnext best option30% of these patients will not reperfuse and will 30% of these patients will not reperfuse and will require “rescue PCI” (“Drip and ship”).require “rescue PCI” (“Drip and ship”).Inverness will only be “office hours” PCI centre Inverness will only be “office hours” PCI centre from Augustfrom August““Double jump” admissions and A&E Double jump” admissions and A&E Departments are to be discouraged as they slow Departments are to be discouraged as they slow down this assessment and time to “rescue” with down this assessment and time to “rescue” with attendant increased mortality/morbidity.attendant increased mortality/morbidity.

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Proposed rules of engagementProposed rules of engagement

IslandsIslands Drip and Ship with immediate air transport to Aberdeen.Drip and Ship with immediate air transport to Aberdeen.

HighlandHighland After August patients within 40 min drivetime (inc W Moray) and After August patients within 40 min drivetime (inc W Moray) and

within office hours to be taken to Raigmore for PPCIwithin office hours to be taken to Raigmore for PPCI Other patients to be given PHT and those which require rescue Other patients to be given PHT and those which require rescue

to be done locally (office hours) or immediate air transport to to be done locally (office hours) or immediate air transport to Aberdeen.Aberdeen.

This to be coordinated by local decision support serviceThis to be coordinated by local decision support service Wick, Fort William and Skye probably hybrid of above Wick, Fort William and Skye probably hybrid of above

coordinated by decision support servicecoordinated by decision support service

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Proposed rules of engagementProposed rules of engagement

GrampianGrampian Office hours PPCI currently available with Office hours PPCI currently available with

24/7 emergency service available.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 Other Grampian patients to be given PHT and

shipped to Aberdeen.shipped to Aberdeen. STEMI patients should bypass Dr Grays and STEMI patients should bypass Dr Grays and

all other community hospitalsall other community hospitals

Page 9: Optimal reperfusion in NoS

Proposed rules of engagementProposed rules of engagement

TaysideTayside Office hours PPCI service currently availableOffice hours PPCI service currently available BC acceptance to extend service to 24/7 from BC acceptance to extend service to 24/7 from

AprilApril May include N Fife tooMay include N Fife too Unusual population as majority live within 40 Unusual population as majority live within 40

mins of Ninewells.mins of Ninewells. Decision support will still direct to PHT with Decision support will still direct to PHT with

transfer to Ninewells as appropriate.transfer to Ninewells as appropriate.

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Discussion…Discussion…

So how do we make this all work?So how do we make this all work?

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Transcatheter aortic valve Transcatheter aortic valve implantation (TAVI)implantation (TAVI)

Malcolm MetcalfeMalcolm Metcalfe

Page 12: Optimal reperfusion in NoS

TAVITAVI

Potentially life-saving therapy for patients unsuitable for Potentially life-saving therapy for patients unsuitable for conventional aortic valve replacement.conventional aortic valve replacement.No longer regarded as experimentalNo longer regarded as experimentalAt the end of 2009 c 8000 valves were implanted world-At the end of 2009 c 8000 valves were implanted world-wide.wide.2 major competitors2 major competitors

Medtronic Core-ValveMedtronic Core-Valve Edwards SapienEdwards Sapien

3 methods of implantation3 methods of implantation Trans-arteriallyTrans-arterially Trans-apicallyTrans-apically Subclavian approachSubclavian approach

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““Surgical Surgical intervention intervention should be should be performed performed promptly once promptly once even… minor even… minor symptoms occur”symptoms occur”11

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):61-7.

Valvular Aortic Stenosis in Adults

(Average Course)

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Mortality in Aortic Valve ReplacementMortality in Aortic Valve Replacement

Burr et al, Annals Thor Surg, 1995;60:S264-269

n = 1.984n = 1.984

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Calculated numbersCalculated numbers

Probably 1000 for UK as a wholeProbably 1000 for UK as a whole

c100 for Scotlandc100 for Scotland

= 16 per million of population= 16 per million of population

Page 17: Optimal reperfusion in NoS

What is the risk?What is the risk?

Initial mortality approximately 10%Initial mortality approximately 10%

ImprovingImproving Core valve May 2008: 30 day mortality = 8% Core valve May 2008: 30 day mortality = 8%

in first 1000 European implantsin first 1000 European implants Edwards May 2009: 30 day mortality = 6.3% Edwards May 2009: 30 day mortality = 6.3%

for TAVI and 10.3% for trans-apical in 1038 for TAVI and 10.3% for trans-apical in 1038 patients.patients.

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Risks and benefitsRisks and benefits

3 year experience (Vancouver data to be 3 year experience (Vancouver data to be published in Circulation)published in Circulation) 168 patients, mean age 84. 168 patients, mean age 84. TAVI = 113TAVI = 113 Trans-apical = 55Trans-apical = 55

Major complicationsMajor 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% MACCE @ 30 days 14.9% MACCE @ 30 days 14.9%

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Risks and benefits – Vancouver Risks and benefits – Vancouver experienceexperience

MortalityMortality p valuep valueTransarteriallyTransarterially

overalloverall 8.0%8.0% 0.160.16

11stst half half 12.3%12.3%

22ndnd half half 3.6%3.6%

TransapicallyTransapically

overalloverall 18.2%18.2% 0.300.30

11stst half half 25%25%

22ndnd half half 11.1%11.1%

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Risks and benefits – Vancouver Risks and benefits – Vancouver experienceexperience

Benefits were sustainedBenefits were sustained All NYHA class 3 & 4 patients improved by 1 All NYHA class 3 & 4 patients improved by 1

class.class. At 1 year 75% still alive (99) of which 77 were At 1 year 75% still alive (99) of which 77 were

in class 1 or 2.in class 1 or 2.

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CentresCentres

All 3 Scottish cardiothoracic centres could be All 3 Scottish cardiothoracic centres could be capable of undertaking these procedures.capable of undertaking these procedures.Stringent criteria laid down as per formal Stringent criteria laid down as per formal commissioning framework (DH 3/09)commissioning framework (DH 3/09)Centres must undertake 25-50 implants in first Centres must undertake 25-50 implants in first year and maintain this.year and maintain this.At 16 per million population = 90-100 pa for At 16 per million population = 90-100 pa for ScotlandScotlandInitial rate may be lessInitial rate may be lessExpensive, 50% more than conventional AVRExpensive, 50% more than conventional AVRThus need to decide how to deliver serviceThus need to decide how to deliver service

Page 22: Optimal reperfusion in NoS

Genie is now out of the bottle – Genie is now out of the bottle – how to progress servicehow to progress service

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