92A GERIATRICIAN’S APPROACH TO THE TAVI DECISION MAKING PROCESS

Abstract

Topic: There has been local interest in the involvement of a geriatrician on the TAVI (Transcatheter Aortic Valve Implantation) team and an opportunity arose to collaborate with cardiology colleagues. Drawing on subspecialty expertise in managing heart failure in older people we developed and piloted a geriatric medicine-focused, pre-TAVI assessment based on principles of comprehensive geriatric assessment (CGA). Intervention: Over 18 months we were referred 33 patients aged 70+ in whom the balance of risks and benefits of TAVI were uncertain. Assessment included cognition, mood, nutrition, quality of life, basic and instrumental activities of daily living, physical disability, and frailty. The geriatrician's opinion on TAVI likely benefit was reached by considering frailty grading, and potential reversibility of frailty and disability by a successful TAVI. The management plan focused on areas for optimisation pre and post TAVI. Improvement: A geriatrician's opinion was valued in these cases of uncertainty and there was highly statistically significant agreement (k = 0.78; p = 0.001) with the TAVI multidisciplinary team (MDT) final decision. The strongest predictors of TAVI MDT decision were CSHA clinical frailty scale, a 32-item mathematical frailty index, and global frailty grading by a geriatrician (all p < 0.05). However, CGA remained the cornerstone of the assessment process and frailty measures supplemented rather than dictated our decision. We are now part of the steering group on TAVI clinical policy, findings have been presented nationally and there is a drive to involve a geriatrician as an integral part of the TAVI MDT. Discussion: Patient selection for TAVI is challenging but geriatricians have significant expertise in CGA. The time-consuming nature of the assessment, all undertaken by the geriatrician, was feasible in a dedicated day hospital session but future service development would benefit from input from the geriatric medicine MDT, who may also have a re-ablement role post-TAVI.