Performing TAVI in a hybrid operating room

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Hybrid operating rooms (ORs) allow cardiac surgeons and interventional cardiologists to work together to perform minimally invasive procedures such as transcatheter aortic valve implatation (TAVI). Daniel O’ Hair (Cardiovascular and Thoracic surgeon at Aurora St Luke’s Medical Center in Milwaukee, USA), believes hybrid ORs may provide “distinct advantages” for complex TAVI cases. He speaks to Cardiovascular News about his experience of performing TAVI in a hybrid OR.

What are the key features of a hybrid OR?

The key features of a hybrid operating room involve a combination of the essential elements of a cardiac surgery operating room and imaging technology that is otherwise reserved for the cath lab or radiology suite. These hybrid ORs are sterile environments with laminar air flow and not only have all the instruments needed for complex surgery, but they also house state-of-the-art imaging. We have the GE Discovery 730 at our institution, which—uniquely—is not mounted on the floor. This means it can come and go from the patient’s side as needed, which allows physicians both good imaging and access to the patient. This combination allows surgeons and cardiologists to interact as a close team that enables us to treat patients together in a way not previously possible. This results in fewer complications and reduced morbidity.

How does a hybrid operating room enable interventional cardiologists to perform minimally invasive procedures such as TAVI?

The physician-governing societies, including the Society of Thoracic Surgeons (STS) and the American College of Cardiology (ACC), along with US federal government, have agreed that TAVI should be done with the surgeon and cardiologist working together to place the valve. The sterile environment of the hybrid OR allows for safe implant of the valves into the human body while minimising risk of infection. The hybrid OR also allows adjunctive surgical procedures to be done without moving the patient to another operating room and prompt treatment if a surgical intervention becomes necessary.

What data are available for TAVI performed in hybrid ORs compared with surgeries in traditional operating rooms?

There is no prospective, risk adjusted or multicentre data for this topic. However, anecdotal experience suggests that TAVI can be performed in either environment. In my view, more complex procedures, those requiring circulatory support, or unplanned procedures may have a distinct advantage in the hybrid OR setting.

What is your experience of using a hybrid OR to perform TAVI?

At our institution, we have used the hybrid OR for TAVI procedures in many cases now. The availability of full anaesthetic support has allowed us to transition to conscious sedation to treat our TAVI patients. This further reduces morbidity by avoiding endotracheal intubation and general anaesthetic.

What have been the key developments in hybrid operating rooms in recent years?

One of the biggest advances is the development of imaging systems that can move around the room to approach the patient from multiple directions as the situation requires. Also, such systems can be removed immediately if surgical intervention becomes necessary.

If setting up a hybrid OR at an institution, what key features need to be considered?

Key planning includes a multidisciplinary team with including representatives from surgical, interventional, imaging and anaesthetic teams. Physical space is key and integration of imaging modalities including echo, angiography and haemodynamic monitoring are all essential.

What data are available for the cost-effectiveness of installing a hybrid operating room?

While hard data for this subject does not exist, there are clear data that reducing hospital stay, avoiding complications and preventing unnecessary intensive care unit (ICU) admission for heart failure are essential to cost effective care of patients with aortic stenosis.

With advanced imaging, radiation exposure is always a concern. What steps can be taken to reduce radiation exposure to both the patient and the operator in hybrid operating rooms?

Careful monitoring is essential. Minimising frame rate and use of available shielding are essential. We have found that the Discovery 730 allows significant reduction in frame rate while maintaining good imaging characteristics. Experienced centres can now implant TAVI valves with less than 10 minutes of fluoroscopy time.