Horizon Scanning

1. Horizon Scanning North of Scotland Cardiac Services Pam Lowbridge & Malcolm Metcalfe

2. An overview of potential future issues and trends that may have an impact on policy and planning HorizonScanning

3. Change in population Projected rates pmp over 10 years Projected increase in procedures over 10 years Projected future need

4. Population change to 2020 Based on GRO Projected Population of Scotland 2008-based (published 21/10/09)

5. Overall population projected to increase by 4.9% over the next 10 years Over 45 population projected to increase from 46.6% to 49.6% of total population Over 65 population projected to increase from 18.1% to 22.2% of total population Based on GRO Projected Population of Scotland 2008-based (published 21/10/09) Population change to 2020

6. Population change to 2020 Based on GRO Projected Population of Scotland 2008-based (published 21/10/09)

7. Projected increase in procedures Based on Oxford Healthcare Associates Access to Cardiac Care in the UK report (June 2009)

8. New EPS/ablation shows highest projected rise in the number of procedures over the next 10 years Revascularisation shows highest projected rate pmp over the next 10 years Projected future need

9. Projected rates pmp Based on Oxford Healthcare Associates Access to Cardiac Care in the UK report (June 2009)

10. Optimal Reperfusion Therapy CT coronary angiography Device closure PAVR / TAVI PMVR Dabigatran Technologies & Treatments

11. Could potentially replace up to 20% of catheter coronary angiograms This would equate to over 1250 cases across North of Scotland p.a. Suitable for selected patients only – e.g. the use of betablockers means the technique is unsuitable for asthmatics Technique being used in NHS Highland CT coronary angiography

12. Started CTCA in June 2007 with regular sessions every week from 2008 250 patients have undergone CTCA to date with 50% avoiding a catheter study Estimated that CTCA represents a 66-88% saving on the cost of a catheter angiography per patient CTCA takes 30 mins, with the scan lasting 30 seconds CTCA NHS Highland

13. Positive effect on performance of radiographic staff who are challenged by this work Requires training of technical and medical staff Catheter studies only show the lumen whereas CTCA shows the lumen and the wall (where the pathology is) NHS Highland comments provided by Dr John Miller, Consultant Radiologist, Raigmore Hospital CTCA NHS Highland

14. All device closures currently performed outwith North of Scotland PFO (Patent Foramen Ovale) closures could be performed in Aberdeen – estimated minimum of 12 per year More complex procedures would remain in Edinburgh/Glasgow Device closure

15. Percutaneous Aortic Valve Replacement / Transcatheter Aortic Valve Implantation Emerging technology Long-term durability and efficacy unknown Procedure performed at a limited number of centres across the UK PAVR / TAVI

16. 'evidence on TAVI for aortic stenosis is limited to small numbers of patients who were considered to be at high risk for conventional cardiac surgery. It shows good short-term efficacy but there is little evidence on long term outcomes.' NICE interventional procedure guidance IPG266 TAVI

17. British Cardiovascular Intervention Society (BCIS) and the Society of Cardiothoracic Surgeons (SCTS) position statement: Any hospital wishing to set up a TAVI programme should have the following minimum infrastructure available: The ability to set up an MDT drawn from a minimum of 2 interventional cardiologists, 2 cardiothoracic surgeons, cardiac anaesthetists and cardiac imaging specialists. Immediate availability of trans-thoracic and transoesophageal echocardiography. Availability of a dedicated cardiac catheter lab or hybrid theatre. A theatre with “C” arm screening facilities is generally not appropriate for TAVI procedures . CT scanning facilities Immediate availability of perfusion services in case of the need for emergency femoro- femoral bypass. On-site availability of a surgical recovery area and intensive care with staff experienced in looking after patients following surgical aortic valve replacement. Robust arrangements for immediate renal support if necessary. Immediate access to vascular surgeons and interventional radiologists to deal with major peripheral vascular complications. TAVI

18. British Cardiovascular Intervention Society (BCIS) and the Society of Cardiothoracic Surgeons (SCTS) position statement: occasional practice and small volume TAVI units should be actively discouraged difficult to stipulate a minimum number of cases per year for a TAVI programme a minimum annual number of 24 cases per TAVI unit may be reasonable, but given the learning curve and infrastructure needed somewhere in the order of > 50 cases per year to be optimal TAVI

19. Projected TAVI cases prevalence estimate of around 16pmp as an acceptable target

20. Percutaneous Mitral Valve Repair Percutaneous repairs currently performed by the use of mitral valve clips – procedure carried out at a limited number of centres across the UK Percutaneous valve replacement still in experimental stages PMVR

21. Warfarin replacement which doesn’t require patient monitoring or dose adjustment Cost comparison – Dabigatran cost of £4.20 per patient per day; Warfarin cost of around 42p per patient per day Assuming a 1.1% prevalence rate, with 75% of these patients on Warfarin, comparative North of Scotland annual costs: Warfarin £ 1.65m Dabigatran £16.48m Dabigatran

22. Changing demographics Associated impact on demand Cost/benefit of incorporating new technologies/techniques In summary…