1. The Hybrid OR for Valve Therapy
Mathew Williams, M.D.
Assistant Professor in Surgery and Medicine
Columbia University
New York, NY

2. Disclosures
Consulting: Edwards, Medtronic, Mardil

3. Hybrid Cath Lab/OR Provides full versatility for patient treatment
Availability of all bail-out material
Surgical and interventional equipment
CPB
Anesthesia
TEE
Goal is to treat patients disease not absolutely via the least invasive approach
Complications are difficult to predict

4. Access Issues Ability to quickly convert to alternative access:
Retroperitoneal
Subclavian
Transapical
Traditional Surgery

5. Vascular Injury

8. Valve Dysfunction

9. Other Situations LV perforation Annular or aortic disruption
Valve misplacement

10. Reoperative Procedures
89 yo Severe AS, severe pulm HTN, SVG to OM occluded, RCA occluded, inferior MI, LIMA-LAD patent

11. Logistics - Hybrid OR - ’How to do it’
Define goals
Just Hybrid PCI
Transcatheter Valve
Institution Specific
Hybrid room
Full time hybrid vs. OR vs. Cath lab
Where Located?

12. Administration Convince of Benefit
Encourage very early collaboration in design
Frequent re-visitation
Early planning of staffing

13. Physicians Team of surgeons and interventionalists
Required Regardless
Coordinating Schedules Difficult
Hybrid Trained Specialist
Understands nuances of each approach.
Best and least biased decision maker.
Anesthesia
Must be flexible
Integrating monitoring

14. Staff Nursing Perfusion Xray techs Angioplasty Specialist
Largest Challenge
Hybrid Trained
Cath Lab Nurses
Hemodynamic Monitoring
Turf Battle
Perfusion
Xray techs
Angioplasty Specialist

15. Hybrid Room - Ideal Design
Imaging
Fixed
Large rooms
Storage
Appropriate gas lines, etc
Imbedded IVUS, image processing, injectors, hemodynamics etc.

16. Integrating Equipment
Siemens Zeego
Flexible Table
Volcano IVUS
Acist Injectors
GE Maclab HD
Phillips OR HD
Storz OR One
4 monitors
Cameras
Phillips 3D TEE
Reduced size CPB

17. Tables Full flexibility Moderate flexibility
Not registered with safety mechanisms
Moderate flexibility
Lose ‘Break’ at waist/neck
Slightly less ROM

18. Monitors
Multiple Monitors
Both sides
Accept Several Inputs

20. Finding Ideal Deployment Angle
Rotating 3D volume to an appropriate C-arm angulation.
Every rotation of the volume rendering view corresponds to a C-arm angulation
(up to inplane rotation). Therefore, using the displayed perpendicularity circle the
physician can virtually choose a view that corresponds to appropriate C-arm angulation.
The system then allows to automatically rotate the C-arm to that angulation.

21. Overlay with live fluoro
Starting overlay of visualized 3D structures onto fluoroscopic images.
To overlay the rendered 3D visualization live onto fluoroscopic images, we use a
software available with the angiographic C-arm system (syngo iPilot, Siemens, Erlangen,
Germany). The 3D volume is inherently registered to the fluoroscopic images
because both images are acquired on the same system. The overlay dynamically
adapts to C-arm rotations and table movements (see Figure 4, left). This mode can be
used to adjust or fine-tune the C-arm angulation needed for implantation. The overlay
does not compensate for patient and heart motions, but can be corrected manually in
these cases. 3D
Contour

22. Hybrid Cath Lab/OR Mandatory for TAVI Safest for patient
Complications difficult to predict and some rapidly fatal
Allows unbiased decision in best interest of patient