Multidisciplinary Team Outcomes Research Articles

FP1.3 - SPEC MDT in Aneurin Bevan University Health Board

Abstract Aims The SPEC (significant polyp and early cancer) multi-disciplinary team (MDT) meeting was started in ABUHB in 2022 to discuss complex colonic and rectal polyp cases, such as polyps >20mm, likely to be sessile, or difficult to remove endoscopically. The aim was to evaluate the effectiveness and clinical role of the SPEC MDT. Methods Data for patients discussed in SPEC MDT since its conception in January 2022 until September 2023 was retrospectively collected from the SPEC MDT database, a prospectively collected database. This included patient demographics, reason for referral, polyp characteristics and MDT outcomes. Results In 21 months, there have been 38 SPEC MDTs, with 355 cases discussed (average of 9 cases per MDT). There was at least one laparoscopic colorectal surgeon, gastroenterologist and a histopathologist in every MDT in accordance with BSG guidelines. Main referral reasons included endoscopy findings (72%) and re-discussion post-procedure (22%). Twenty-three patients had adenocarcinomas and three had NETs. MDT outcomes were EMR (23%), endoscopic surveillance (21%), clinic to discuss (no) surgery (19%), TAMIS (16%), urgent endoscopy (13%) or other (8%). Conclusion As the busiest Health Board in Wales for Colorectal Cancers, the formation of SPEC MDT has been an important step in improving the detection and treatment of advanced polyps and early cancers. Although too early to measure the impact on early cancer detection rates and improved decision making for these patients, formalising the MDT process in line with BSG guidelines has been an important step in improving the service offered to patients.

DP04 Role of multidisciplinary team meetings in management of inflammatory skin conditions

Abstract The multidisciplinary team (MDT) model has been previously demonstrated to improve early diagnosis and outcomes for psoriatic arthritis [Zheng YX, Zheng M. A multidisciplinary team for the diagnosis and management of psoriatic arthritis. Chin Med J (Engl) 2021; 134:1387–9; Luelomo J, Gratacós J, Martínez-Losa MM et al. A report of 4 years of experience of a multidisciplinary unit of psoriasis and psoriatic arthritis. Reumatol Clin 2014; 10:141–6]. However, there is little evidence for a similar role in inflammatory skin disease (ISD). A monthly psoriasis MDT has been established in our tertiary referral dermatology centre. We analysed referrals from February 2021 to February 2022. A total of 37 patient cases were discussed, 29 from within the geographical region of the centre and eight from outside the region. Reasons for referral were the presence of comorbidities; in the majority of cases, this was the presence of an internal malignancy (n = 15). Additional comorbidities were organ transplantation (n = 2), inflammatory bowel disease (n = 2), coexisting inflammatory arthritis (n = 4) and history of severe infection (n = 2). The secondary reason for referral was a history of multiple treatment failures (n = 8) and/or adverse effects of current biologics (n = 2). Where outcome data for regional patients could be assessed, the majority (n = 16) subsequently demonstrated objective improvement in their skin condition, with a mean reduction in Psoriasis Area and Severity Index score of 79.0% (n = 16) and a concurrent mean improvement of 59.6% in Dermatology Quality of Life Index (n = 11). Three patients died (unrelated to psoriasis/treatment). In summary, the presence of comorbidities and prior treatment failures are the primary reasons for referral to a tertiary referral service psoriasis MDT. Multidisciplinary team discussion results in objective improvements in patient care at early follow-up assessments. Further data on MDT outcomes for ISD are required.

Neurosurgical Management of Central Nervous System Lymphoma: Lessons Learnt from a Neuro-Oncology Multidisciplinary Team Approach.

Central nervous system lymphoma (CNSL) represents one of the most aggressive forms of extranodal lymphoma. The gold standard for CNSL diagnosis remains the stereotactic biopsy, with a limited role for cytoreductive surgery that has not been supported by historical data. Our study aims to provide a comprehensive overview of neurosurgery's role in the diagnosis of systemic relapsed and primary CNSL, with an emphasis on the impact on management and survival. This is a single center retrospective cohort study with data collected between August 2012 and August 2020, including patients referred with a potential diagnosis of CNSL to the local Neuro-oncology Multidisciplinary Team (MDT). The concordance between the MDT outcome and histopathological confirmation was assessed using diagnostic statistics. A Cox regression is used for overall survival (OS) risk factor analysis, and Kaplan-Meier statistics are performed for three prognostic models. The diagnosis of lymphoma is confirmed in all cases of relapsed CNSL, and in all but two patients who underwent neurosurgery. For the relapsed CNSL group, the highest positive predictive value (PPV) is found for an MDT outcome when lymphoma had been considered as single or topmost probable diagnosis. Neuro-oncology MDT has an important role in establishing the diagnosis in CNSL, not only to plan tissue diagnosis but also to stratify the surgical candidates. The MDT outcome based on history and imaging has good predictive value for cases where lymphoma is considered the most probable diagnosis, with the best prediction for cases of relapsed CNSL, questioning the need for invasive tissue diagnosis in the latter group.

Two-Week Wait Gastrointestinal (GI) Cancer Pathway: A Single Tertiary Centre Experience During the COVID-19 Pandemic.

This article investigated the impact of COVID-19 on the two-week wait referral pathway at the University Hospitals of Leicester NHS Trust. The conversion rate of these referrals was also explored as an indicator of the appropriateness of referrals from primary care. Two-week wait referrals to the Cancer Centre of the University Hospitals of Leicester NHS Trust from 2018 to 2020 were collected for upper gastrointestinal (UGI), lower gastrointestinal (LGI), and hepato-pancreato-biliary (HPB) surgery. The confirmed cancer cases out of these referrals were also recorded. Additionally, the outcomes of the multidisciplinary team (MDT) meetings for all patients discussed in June 2018, 2019, and 2020 were collected, and their staging and treatment data were examined. The number of two-week referrals decreased in 2020 compared to the previous two years across the three specialities. This was more pronounced in April, with a reduction of over 50%. The conversion rate of these referrals increased in 2020 compared to 2018 and 2019 among all three specialities. The increase in conversion rate was statistically significant for LGI referrals (2018 vs 2020 p = 0.0056; 2019 vs 2020 p = 0.0005). There was no significant difference in the MDT outcome across the three specialities. Two-week wait remains a cornerstone pathway in the management of patients with suspected cancer in the National Health Service. The COVID-19 pandemic appeared to have reduced inappropriate referrals, as evidenced by the increased conversion rate. This did not appear to negatively impact tumour staging and outcomes for those patients who were referred on the pathway.

The Effect of COVID-19 on Multidisciplinary Team (MDT) Outcomes for Oesophagogastric Cancer

Background/ Introduction: SARS Cov-2 was classified as a pandemic by the World Health Organization in March 2054 This impacted cancer service delivery worldwide. Medical societies and associations around the world published emergency guidance to deal with cancer cases in response to the pandemic. This study evaluates its effect on new referrals, MDT outcomes and, eventually, the survival of patients at a tertiary Upper Gastro-Intestinal (UGI) centre in the UK. Method: This case-control study includes all new referrals, with early and invasive lesions of the stomach and oesophagus from March to August, in years 2019 and 2020 respectively- Group 1 being the 2019 pre-pandemic control group and Group 2, the 2020 pandemic group. Data was sourced from MDT minutes, electronic patient records and NHS Spine platform. Results/ Discussion: 439 new referrals were made in 2019 and 310 in 2020. 193 (43.96%) patients in Group 1 had MDT outcomes that advocated for curative treatment options as opposed to 124 (40%) in Group 2. One-year overall survival in Group 1 was 233 (53.08%) vs 157 (50.65%) in Group 2 (p-value = 0.512). Median time of death from the date of first MDT discussion was 109 and 108 days for Group 1 vs Group 2 respectively (p-value = 0.6245) Conclusion: Our results demonstrate that MDT performance and one-year survival for UGI cancer was akin to pre-pandemic standards. However, a significant reduction in the number of new cancer diagnoses was noted, possibly affecting patient outcomes in the future. Further studies are needed to evaluate this.

Multidisciplinary Tumor Board in the Management of Patients with Colorectal Liver Metastases: A Single-Center Review of 847 Patients.

Simple SummaryA multispecialty discussion may represent a benefit for cancer patients in receiving the most updated pathway of cure. The aim of this study was to describe the activity of our multidisciplinary team (MDT) meeting on patients with colorectal liver metastases (CRLMs). Information about 847 consecutive CRLMs patients over an 11-year period was retrospectively collected. Their characteristics were analyzed, and the populations were compared based on received treatment.There is still debate over how reviewing oncological histories and addressing appropriate therapies in multidisciplinary team (MDT) discussions may affect patients’ overall survival (OS). The aim of this study was to describe MDT outcomes for a single cancer center’s patients affected by colorectal liver metastases (CRLMs). From 2010 to 2020, a total of 847 patients with CRLMs were discussed at our weekly MDT meeting. Patients’ characteristics and MDT decisions were analyzed in two groups: patients receiving systemic therapy (ST) versus patients receiving locoregional treatment (LRT). Propensity-score matching (PSM) was run to reduce the risk of selection bias. The median time from MDT indication to treatment was 27 (IQR 13–51) days. The median OS was 30 (95%CI = 27–34) months. After PSM, OS for patients undergoing LRT was 51 (95%CI = 36–64) months compared with 15 (95%CI = 13–20) months for ST patients (p < 0.0001). In this large retrospective study, the MDT discussions were useful in providing the patients with all available locoregional options.

151 THERAPY OUTCOME MEASURES IN AN OLDER PERSONS REHABILITATION UNIT

Abstract Background The mission of an older person’s sub-acute rehabilitation unit is to improve the individual’s function and quality of life. This is achieved through patient and multidisciplinary team (MDT) collaboration. The MDT collect Therapy Outcome Measure (TOM) (Enderby and John 2015) data to measure the effectiveness of rehabilitation and facilitate analysis of patient and service outcomes. This abstract will present 6 months of data collection with the aim of evaluating the impact of MDT intervention from January 2021. Methods The MDT meet weekly to jointly record patient TOM scores on admission and discharge. The TOM scales used are; multifactorial conditions, stroke and neurological disorder. The patient is scored from 0–5 in four domains; impairment, activity, participation and well-being. There are 11 parts to the scale with 0.5 scores permitted (Enderby and John 2015). Results Data was analysed on 62 patients. Across an episode of rehabilitation an increase of 0.5 or more on the TOM is a clinically significant (positive) change. 84% of patients had an overall improvement in the total TOM score. There was an average overall increase of 2.6 points on the scale which equates to a 25% overall change. 63% improved in the domain of impairment, 77% in activity, 73% in participation and 66% in wellbeing. 100% of patients post-stroke, 81% with multifactorial conditions and 75% with neurological conditions experienced an overall improvement. Conclusion The data objectively shows positive patient outcomes in older persons rehabilitation. Individuals experienced the most positive change in their activity and participation function and high levels of change are also evident in impairment levels and well-being. Overall, TOM is a very useful MDT outcome measure tool. It has been successfully implemented and maintained in the service and facilitates the ongoing analysis of individual and service outcomes to understand the impact of intervention.

Exploring the impact of uro-oncology multidisciplinary team meetings on patient outcomes: A systematic review.

Multidisciplinary team (MDT) meetings are mainstay clinical management globally. Clinical guidelines state that patients should be considered for MDT review, but evidence has identified that within the specialty of uro-oncology not all patients are reviewed by an MDT. This systematic review aimed to understand the impact of uro-oncology MDT meetings on patient outcomes, to explore how patient engagement is incorporated in the process, and to identify the barriers and facilitators within an MDT. A systematic review was reported according to PRISMA guidelines. Electronic databases (MEDLINE, CINAHL and PsychINFO) were searched in EBSCOhost from January 2010 to March 2021, using a range of key search words. Studies were assessed for inclusion according to a pre-defined eligibility criteria. Data extraction and quality assessment was undertaken. The findings were tabulated, and a narrative synthesis undertaken. 373 articles were screened, and seven studies were included. The studies were conducted in a range of international countries which provided an overview of uro-oncology MDTs in different healthcare contexts. The following themes were identified: 1) MDT and clinical outcomes, 2) structure and format, 3) patient engagement in the process, and 4) barriers and facilitators. Cancer care is constantly being challenged due to complex newer therapies, including multimodality treatments, and newer emergent broader considerations such as, oncogeriatrics, genetic counselling, and survivorship issues which should have a central place for consideration in the MDT.

Current decision support tools fail to agree or predict therapeutic decisions in a single cohort of unruptured intracranial aneurysms

BackgroundThere is limited evidence to direct the management of unruptured intracranial aneurysms. Models extrapolated from existing data have been proposed to guide treatment recommendations. The aim of this study is to assess whether a consensus-based treatment score (UIATS) or rupture rate estimation model (PHASES) can be used to benchmark UK multi-disciplinary team (MDT) practice.MethodsProspective data was collected on a consecutive series of all patients with unruptured intracranial aneurysms (UIAs) presenting to a major UK neurovascular centre between 2012 and 2015. The agreement between the UIATS and PHASES scores, and their sensitivity and specificity in predicting the real-world MDT outcome were calculated and compared.ResultsA total of 366 patients (456 aneurysms) were included in the analysis. The agreement between UIATS and MDT recommendation was low (weighted kappa 0.26 [95% CI 0.19, 0.32]); sensitivity and specificity were also low at 36% and 52% respectively. Groups that the MDT allocated to treatment, equipoise or no treatment had significantly different PHASES scores (p = 0.004). There was no significant difference between the two scores when predicting patients for whom MDT outcome was to recommend aneurysm treatment, but the UIATS score was superior in predicting patients who received an MDT recommendation of ‘treatment-equipoise’, or ‘not-for-treatment’ (AUC of 0.73 compared to 0.59 for PHASES).ConclusionsThe models studied failed to agree with the consensus view of multi-disciplinary team in a major neurovascular centre. We conclude that decision support tools such as the UIATS and PHASES scores should not be blindly introduced in respective institutions without prior internal validation, as they may not represent the local reality.

Validating the Developmental and Well-Being Assessment (DAWBA) in a clinical population with high-functioning autism

Background: With increasing numbers of referrals to health services for assessment of Autism Spectrum Disorder (ASD), the Developmental and Well-Being Assessment (DAWBA) has been suggested as a useful screening instrument to assist in prioritising patients for review. It is an online interview for parents that has been previously validated for ASD in a non-clinical community sample of twins. Our study aimed to evaluate its predictive validity in a complex clinically-referred sample of children with suspected high-functioning autism. Methods: The sample comprised 136 children (females = 53; males = 83) who were referred for ASD assessment at the Social Communication Disorder Clinic (SCDC) at Great Ormond Street Hospital. Parents completed the DAWBA online prior to undergoing a multi-disciplinary team (MDT) assessment. This included completing the Developmental, Dimensional and Diagnostic Interview (3di) and the Autism Diagnostic Observation Schedule (ADOS). Two clinicians independently rated the DAWBA using DSM-5 diagnostic criteria and compared results to the MDT outcome, which was considered gold standard. Results: Compared with an MDT assessment, the DAWBA interview demonstrated good sensitivity (0.91) but poor specificity (0.12). Overall, 64% of cases were accurately assigned as case/non-case. Estimates of positive (0.66) and negative (0.43) predictive validity were influenced by the relatively high prevalence of ASD in the study sample (65%). Conclusion: The DAWBA online interview has excellent sensitivity in a clinical population of complex neurodevelopmental disorders, containing a high prevalence of ASD, but specificity was poor. As the SCDC offers tertiary opinions on disputed cases of suspected ASD, the population cohort limits the generalisability of these results. Further evaluation is required in community child mental health or paediatric services.

FFR-CT strengthens multi-disciplinary reporting of CT coronary angiography.

The utility of computed tomography (CT) coronary angiography (CTCA) is underpinned by its excellent sensitivity and negative-predictive value for coronary artery disease (CAD), although it lacks specificity. Invasive coronary angiography (ICA) and invasive fractional flow reserve (FFR), are gold-standard investigations for coronary artery disease, however, they are resource intensive and associated with a small risk of serious complications. FFR-CT has been shown to have comparable performance to FFR measurements and has the potential to reduce unnecessary ICAs. The aim of this study is to briefly review FFR-CT, as an investigational modality for stable angina, and to share 'real-world' UK data, in consecutive patients, following the initial adoption of FFR-CT in our district general hospital in 2016. A retrospective analysis was performed of a previously published consecutive series of 157 patients referred for CTCA by our group in a single, non-interventional, district general hospital. Our multi-disciplinary team (MDT) recorded the likely definitive outcome following CTCA, namely intervention or optimised medical management. FFR-CT analysis was performed on 24 consecutive patients where the MDT recommendation was for ICA. The CTCA + MDT findings, FFR-CT and ICA ± FFR were correlated along with the definitive outcome. In comparing CTCA + MDT, FFR-CT and definitive outcome, in terms of whether a percutaneous coronary intervention was performed, FFR-CT was significantly correlated with definitive outcome (r=0.471, p=0.036) as opposed to CTCA + MDT (r=0.378, p=0.07). In five cases (21%, 5/24), FFR-CT could have altered the management plan by reclassification of coronary stenosis. FFR-CT of 60 coronary artery vessels (83%, 60/72) (mean FFR-CT ratio 0.82 ± 0.10) compared well with FFR performed on 18 coronary vessels (mean 0.80 ± 0.11) (r=0.758, p=0.0013). In conclusion, FFR-CT potentially adds value to MDT outcome of CTCA, increasing the specificity and predictive accuracy of CTCA. FFR-CT may be best utilised to investigate CTCAs where there is potentially prognostically significant moderate disease or severe disease to maximise cost-effectiveness. These data could be used by other NHS trusts to best incorporate FFR-CT into their diagnostic pathways for the investigation of stable chest pain.

Differentiating Simple Hepatic Cysts from Mucinous Cystic Neoplasms: Radiological Features, Cyst Fluid Tumour Marker Analysis and Multidisciplinary Team Outcomes

Background: Differentiating hepatic mucinous cystic neoplasms (MCNs) from simple hepatic cysts (SCs) preoperatively is a challenging task. Our aim was to determine whether radiological features on ultrasound scan (USS), CT or MRI, cyst fluid tumour markers, or multidisciplinary team (MDT) outcomes could differentiate MCN from SC. Methods: A retrospective review of radiological features, cyst fluid tumour marker levels and MDT outcomes in 52 patients was performed. Results: There were 13 patients with MCN, 38 with SC and one ciliated foregut cyst. MCNs were more often solitary (p = 0.006). Although no other individual radiological characteristic on USS, CT or MRI was predictive of MCN, MDT outcomes stating that a cyst was complex in nature were highly predictive (p = 0.0007). Cyst fluid carbohydrate antigen 19-9, carcino-embryonic antigen and cancer antigen 125 were unable to differentiate MCN from SC (p = 0.45, p = 0.49, and p = 0.73, respectively). Conclusions: MDT outcomes are of greatest value when trying to differentiate MCN from SC, as well as having a solitary cyst on imaging. Conventional cyst fluid tumour markers are unhelpful. All suspicious cystic liver lesions should be discussed pre-operatively by a hepatobiliary MDT to determine the most appropriate surgical approach.

PTH-141 Gastrointestinal Malignancy – Same Day CT Scanning Post Endoscopy Saves Time Resulting in Earlier MDT Decisions

Introduction Staging CT scanning is essential in guiding the management of patients with newly diagnosed gastrointestinal malignancy when discussed in multi-disciplinary team (MDT) meetings. Long waiting times for staging CT causes delays in MDT decision making for patients and initiating treatment. Kettering General Hospital (KGH) implemented a pathway in December 2014 in which patients with newly detected malignancy on endoscopy can have staging CT scan post endoscopy (same day). We are auditing the effectiveness of this pathway in terms of time saved. Methods Data was analysed between January 1st 2014 to December 31st 2015 from endoscopy, radiology and cancer MDT reporting systems to compare time from day of endoscopy to day of CT and to date of MDT discussion pre and post implementation of the pathway. Patients who underwent endoscopy in December 2014 were excluded, as the pathway was being implemented. Results There were 90 and 104 patients found to have new possible malignancy on endoscopy in 2014 and 2015 respectively. The median (and mean) days awaiting staging CT and MDT discussion prior to the pathway were 12.5 (11.4) days and 15.0 (16.0) days respectively. Since the implementation of the pathway, median (and mean) days for staging CT was 0 (1.6) days and MDT discussions were 6.0 (7.2) days (p = Conclusion This data shows significant improvement in median time to MDT discussion from endoscopy since the pathway was implemented (15 vs 6 days). The patient pathway implemented by our organisation has helped shortened decision time for MDT outcomes and is highly effective in improving patient care. Patients are diagnosed and staged quickly, requiring fewer visits to the hospital and starting their treatment earlier. We commend this pathway to other endoscopy / radiology departments around the country. Disclosure of Interest None Declared

Reducing health inequalities in people with learning disabilities: a multi-disciplinary team approach to care under general anaesthesia.

Background There remains significant inequality in health and healthcare in people with learning disabilities (LD). A lack of coordination and the episodic nature of care provision are contributory factors. Recognising the need to improve outcomes for this group, we evaluate a multi-disciplinary team (MDT) approach to care whereby additional medical procedures are carried out under the same episode of general anaesthesia (GA) as dental treatment for people with severe LD. This is the first published evaluation of its kind in the UK.Aim To evaluate the need and outcomes of an MDT approach to care among people with severe LD receiving dental treatment under GA.Method One hundred patients with severe LD and behaviour that challenges attended Barts Health Dental Hospital for dental assessment and subsequent treatment under GA. Details of failed or forthcoming medical interventions were determined. Where appropriate, care was coordinated with the relevant medical team.Findings Twenty-one percent (n = 21/100) had recent medical interventions attempted that had been abandoned, and 7.0% (n = 7/100) had future investigations or treatment planned under GA with medical specialties. An MDT approach was indicated in 28.0% (n = 28/100). For such complex cases, a successful MDT outcome was achieved in 89.3% (n = 25/28). This included ophthalmological/orthoptic, ENT and gastroenterological interventions in addition to medical imaging.Conclusion An MDT approach to care for people with LD offers improved patient-centred outcomes in addition to financial and resource efficiency. It requires a high level of cooperation between specialties, with consideration of the practicalities of a shared surgical space and equipment needs. Re-shaping of services and contractual flexibility are essential to support the future implementation of MDTs and to ensure long-term sustainability. Adoption of a holistic culture in the care of this vulnerable patient group is encouraged.

Improving care for patients with oesophageal and gastric cancer: impact of a statewide multidisciplinary team.

To standardize management of upper gastrointestinal (GI) cancer in South Australia, a statewide video linked multidisciplinary team (MDT) meeting was established in late 2009. Although cancer MDTs are recognized as a standard of care, it is important to audit their impact. A retrospective audit of MDT outcomes and recommendations for patients reviewed by the upper GI MDT between 1 January 2010 and 31 December 2011 was undertaken. The proportion of patients with new upper GI malignancies reviewed and the proportion reviewed within 2 weeks of diagnosis were determined. Recommendations from the MDT meetings regarding treatment intent, management, investigations and trial participation were audited. From 2010 to 2011, the proportion of newly diagnosed upper GI malignancies in South Australia reviewed by the MDT increased from 43.2% to 54.3%. More oesophageal than gastric cancer cases were reviewed by the MDT. The proportion of patients reviewed within 2 weeks of diagnosis increased from 20% to 50%. The proportion of patients referred for neoadjuvant or definitive chemoradiotherapy increased from 2010 to 2011. Fifty per cent of all patients reviewed were recommended to have further investigations. Recommendations for clinical trial participation increased from 0% in 2010 to 11% in 2011. A statewide upper GI cancer MDT is feasible. Implementation of the MDT was followed by an increase in the number of patients reviewed and the proportion reviewed within 2 weeks of diagnosis. Greater awareness of the MDT and access to it may be required to continue to increase the proportion of cancers reviewed.

S12 Interstitial lung disease multidisciplinary discussion: six years of data from a tertiary service

IntroductionAccurate diagnosis in Interstitial Lung Disease (ILD) is vital in optimising patient management. An integrated approach involving a multidisciplinary team (MDT) of physicians, radiologists and pathologists is strongly advised in...

PWE-032 What is the Impact of the Introduction of the NHS Bowel Cancer Screening Programme on the Workload of a Colorectal Surgery Unit at a District General Hospital?

IntroductionA study to assess the impact of the introduction of the National Bowel Cancer Screening Programme (BCSP) on the workload of a colorectal unit in a medium-size general hospital covering...

PTU-150 Concordance between Endoscopic Ultrasound (EUS) and Positron Emission Tomography (PET) in the Staging of upper Gastrointestinal Cancer – a District General Experience

IntroductionApproximately 1700 patients/year are diagnosed with oesophageal or gastric cancer in Scotland. The Scottish Audit of Gastric and Oesophageal Cancer (SAGOC) previously reported under-staging of these cancers pre-operatively with curative...

093 Treatment of high risk aortic stenosis in 2010—more than just TAVI

Introduction The treatment of high risk patients with severe aortic stenosis (AS) has been transformed by the availability of transcatheter aortic valve implantation (TAVI) alongside conventional high risk aortic valve replacement (AVR). Selection of patients for this procedure is clinically challenging and best achieved using a dedicated and experienced multidisciplinary team (MDT). A TAVI programme was established at our institution in September 2008 and the MDT from the outset comprised two interventional cardiologists, an imaging specialist, two cardiac surgeons, cardiac anaesthetist, general cardiologist and a nurse specialist. We report the MDT decision and outcome of 135 patients referred over the subsequent 15 months and the implication on service provision for all aspects of the management of AS. Methods Clinical details of all patients referred to the high-risk aortic stenosis MDT were recorded and analysed prospectively. Outcome data were derived from the hospital database. Results One thirty five patients (mean age 82 years, 50% male) were referred to the high-risk AS MDT (51% local cardiologists, 4% local surgeons, 34% DGH, 11% out of region). Many patients were referred with sufficient data to allow decision making and 45 underwent detailed assessment prior to consideration of TAVI (either following an index inpatient event or during elective admission). To date, 29 of the 135 referred (20%, mean logistic Euroscore 20%) have undergone TAVI (nine apical and 20 femoral) with one (3.4%) procedural mortality, 30-day survival rate 90% and post-TAVI permanent pacemaker requirement 31%. Ten patients (mean logistic Euroscore 22%) were unsuitable for TAVI but appropriate for palliative balloon valvuloplasty either due to significant left ventricular impairment or the presence of co-existent disease with impact on life expectancy. This procedure was undertaken with no in-hospital mortality, a mean reduction in trans-valvular gradient of 25% and a 30-day mortality of 5%. Thirteen patients (mean logistic Euroscore 17.6%) have been referred for high risk AVR. There was one death (8%) 47 days post-AVR. Continued medical therapy was recommended in 27 patients (20 excessive risk or unsuitable for TAVI or valvuloplasty, seven non-severe AS or alternative irreversible aetiology for symptoms eg, pulmonary disease). Overall 12-month mortality for the entire cohort was 20%, highest mortality being seen in those patients deemed too high risk for any form of intervention (41%). Two patients died of AS while the TAVI programme was being conceived. Conclusion Many patients with severe AS previously felt to be at excess risk for any intervention may be suitable for TAVI, surgical AVR or balloon valvuloplasty. Careful patient selection undertaken by a specialist MDT leads to excellent survival outcomes even in this high-risk patient population. The introduction of TAVI has increased surgical referral for AVR and re-introduced balloon valvuloplasty as a successful method of treatment.