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The Hybrid OR: An Interventional and Surgical Perspective
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Since its inception, the hybrid operating room has bridged the once great divide between interventionalists and surgeons and in its place has created what is now referred to as the “cardiac team” approach.
With this transformative concept still relatively in its infancy, Cardiology Today’s Intervention reached out to Amar Krishnaswamy, MD, and E. Murat Tuzcu, MD, with the Cleveland Clinic, and Faisal G. Bakaeen, MD, with the Baylor College of Medicine and the Texas Heart Institute, Houston, who have each worked extensively in hybrid operating rooms (ORs), to get their take on this approach from an interventional and surgical viewpoint.
Interventional Perspective
Interventional cardiology in the modern era provides an extraordinary spectrum of treatments, from hybrid coronary revascularization to transcatheter valve therapies, from carotid intervention to limb salvage. The hybrid procedural suite provides the infrastructure that allows interventionalists to harness the latest technologies and collaborate with our imaging and surgical colleagues to innovate and provide state-of-the art treatments for our patients.
E. Murat Tuzcu
In the arena of structural cardiac interventions, when utilizing large devices and alternate access-points such as transapical puncture, complete sterility is imperative to the safety of the procedure just as in a traditional operating room. The hybrid suite must therefore contain a laminar air-flow system with high-efficiency particulate air (HEPA) filters. It is also important that the room is constructed in such a manner as to allow nurses, technicians and specialists from multiple departments to function together in a way that is comfortable and ergonomic. For instance, the anesthesiology team must have adequate room at the head of the table to manage the patient and monitor their necessary equipment. Similarly, the imaging specialists must be able to conduct their transesophageal echocardiography (TEE) without fear of injury by the moving C-arm. Surgical lighting is also necessary to provide optimal visualization of the field, especially in cases where combined surgical and percutaneous methods are employed or if surgical backup becomes necessary during an initially percutaneous procedure.
Amar
Krishnaswamy
Many advances in percutaneous technologies have been made possible by the availability of multimodality imaging to guide these procedures. We find procedural intracardiac echocardiography (ICE) and TEE (with 3-D capability) indispensible in performing a number of our structural cardiac interventions, such as paravalvular leak closure or transcatheter aortic valve replacement. Furthermore, the contemporary C-arm is capable of acquiring CT-like images that can be overlaid onto the real-time fluoroscopic image. This provides an additional layer of procedural guidance to structural and peripheral interventions. It is therefore necessary for the modern hybrid suite to contain all of the appropriate imaging equipment, as well as enough monitors positioned in such a way that the operators can simultaneously view the adjunctive imaging along with the routine fluoroscopy and hemodynamic monitors.
Because many of the procedures conducted in hybrid suites are at the forefront of the field, they often carry a high degree of procedural risk. It is therefore important that the hybrid suite contain ready-made “crash carts” consisting of any equipment necessary in case of an emergency. In the case of our hybrid suite, we have one cart containing all of the tools necessary to initiate emergent cardiopulmonary bypass and another cart for emergent peripheral endovascular intervention.
Figure 1. The hybrid procedural suite at the Cleveland Clinic. The bank of monitors provides the operators with simultaneous access to biplane fluoroscopic imaging, IVUS, echocardiographic and CT imaging, hemodynamic data and prior studies. Behind the monitors are various equipment "crash carts," and the OR lighting is seen to the left.
Image: Cleveland Clinic Department of Photography
Recent years have seen a palpable change in the relationship between cardiology and cardiac surgery, culminating in the multidisciplinary “heart team” approach. The team embodies the core philosophy that our patients receive the best care when their problems are assessed from many angles, and their treatment may be manifest by a combination approach of medical, percutaneous and/or surgical methods. The hybrid procedural suite is the embodiment of that ideal to which the heart team strives.
Disclosure: Krishnaswamy and Tuzcu report no relevant financial disclosures.
Surgical Perspective
Hybrid ORs have become quintessential features of all modern CV operating suites. Vascular surgeons have been using hybrid ORs for some time now to perform aortic and peripheral interventions, but cardiac surgeons are latecomers to the hybrid era. Some cardiac surgeons became familiar with hybrid ORs when thoracic endovascular repair took off during the last decade, but most cardiac surgeons have been introduced only recently to the hybrid OR. This exposure is largely due to transcatheter cardiac therapies, mainly TAVR.
Faisal G. Bakaeen
It is estimated that 40,000 patients worldwide have undergone TAVR with various transcatheter devices (Holmes DR. J Am Coll Cardiol. 2012;59:1200-1254). This and other transcatheter developments have caught the attention of cardiac surgeons worldwide. The message of the times is clear: Embrace the new technology and re-tool, or risk being obsolete. The sharp decline in coronary artery bypass operations that followed the introduction of PCI has served as a reality check for any surgeon who doubts the future importance of transcatheter valvular therapies.
For the surgeon, the hybrid OR is ideally a room in which both traditional open surgical and image-guided interventions can be done simultaneously or interchangeably in a seamless fashion. The hybrid OR accommodates all open cardiac equipment, including the heart-lung machine, mechanical support devices, ablation devices, light sources and flow meters. In addition, it houses anesthesia equipment, fluoroscopy and cath lab equipment, and an array of other adjuncts.
All stakeholders, including cardiac surgeons and cardiologists, should participate in the planning of new hybrid ORs to ensure an optimal final product. Planning meetings at our centers involved a multidisciplinary team of clinicians, engineers and multiple vendors. The products of these vendors, including imaging equipment and displays, video integration, booms, lights and monitors, should be capable of full integration without conflict. Many surgeons prefer ceiling-mounted systems to floor-mounted ones because the ceiling-mounted systems keep floor space free for OR traffic.
Figure 2. The hybrid OR at the Texas Heart Institute.
Image: Texas Heart Institute
The typical fluoroscopy bed does not allow the range of maneuverability that a surgeon is used to having during open cardiac cases. In addition, some beds lack railings for attaching surgical retractors and adjuncts. Some fluoroscopy beds are now “surgeon friendly,” combining virtually all imaging and open surgical features. Some centers use fluoroscopy beds that can be moved completely out of the way so that a surgical bed can be brought in for open cases.
Access to the blood bank, pharmacy, sterilization and processing areas, and surgical instruments is crucial, especially for cases that require emergency surgical intervention. Unexpected conversions to treat complications of transcatheter procedures can be very challenging and require rapid and exhaustive deployment of expertise and resources. This is why surgeons prefer the hybrid OR to be located in, or at least near, the main OR area. At our facility, the draping and room are always set up as for an open case, even if the intended procedure is a transcatheter one.
We are in a new era of closer collaboration and overlap between cardiothoracic surgeons and cardiologists. The hybrid OR allows the synergism of their expertise and the application of cutting-edge technology to optimize patient care.
Disclosure: Bakaeen reports no relevant financial disclosures.