Disclosure: Dr. O’Hair reports he is a consultant for Medtronic functioning as a proctor for Corevalve implant and Teaching Faculty for TAVR best practices.

Dr. Daniel O’Hair can be contacted at daniel.ohair@aurora.org.

Read more about the structural heart program in the accompanying article: The Structural Heart Program at Aurora St. Luke’s Medical Center

One cannot be too careful when dealing with matters of the heart. 

That is why we are fundamentally shifting how we perform heart-valve surgical procedures at Aurora St. Luke’s Medical Center in Milwaukee, Wisconsin. Leveraging a next-generation hybrid operating room (OR), our team of cardiac surgeons and interventional cardiologists can work together in one room performing minimally invasive procedures with the same level of sterility as open surgery, and the same advanced imaging capabilities of an interventional lab or radiology suite.

The key to our new hybrid OR is the Discovery IGS 730 (GE Healthcare), which aids our physicians in performing complex procedures like endovascular aortic repairs (EVAR), transcatheter aortic valve replacements (TAVR), and atrial fibrillation (AF) ablation. Since integrating the system in late summer 2014, we have increased our number of complex procedures, particularly among patients who would have otherwise been deemed too high risk to undergo such complex procedures in a traditional operating room environment. Almost half of the TAVR patients at Aurora St. Luke’s Medical Center were considered extreme risk and many had been turned down for surgery at other centers.

Because the Discovery IGS 730 is laser guided, not mounted to the floor or ceiling, it gives us the freedom to access the patient and allows for better imaging. The system moves to and from the patient as needed, a benefit especially important for TAVR procedures. Multiple team members need access to the patient, including anesthesiologists, echocardiologists, surgeons, interventional cardiologists, nurses, and technologists. During such procedures, the physicians’ working position varies to accommodate patients’ vascular anatomy: implants usually inserted percutaneously through the femoral arteries may need to be inserted through alternative surgical access such as transapical or subclavian, or direct aortic access in more than 20% of cases.¹ 

In the event that surgical intervention is necessary, the system can be removed immediately. The benefit of this mobility and access translates into fewer complications and reduced morbidity, and we are confident that the mobility, freedom and access that the Discovery system offers is the future of interventional cardiology and cardiac surgery. 

According to the ECRI Institute, an independent, nonprofit organization that researches the best approaches to improving the safety, quality and cost-effectiveness of patient care, by 2018, 75% of cardiovascular surgeons will be working in hybrid OR suites.² With the hybrid OR, we are clearly seeing increased clinical benefits and reduced procedure times, which can produce shorter hospital stays and faster recovery times for specific types of procedures, as well as overall cost savings. 

• Research has shown clear benefits from designing adaptable environments such as the hybrid OR that integrate these surgical and imaging services, allowing endovascular approaches (such as for EVAR) which result in reduced mortality (0.5% vs 3.0%), shorter procedure time (2.9 vs. 3.7 hours), and less blood loss (200 vs. 1000ml) in patients with abdominal aortic aneurysm.³
• Compared to open surgery, TAVR procedures done in the hybrid environment decrease one-year mortality (14.2% vs 19.1%), and significantly reduced major bleeding, acute kidney injury, and atrial fibrillation when compared to conventional AVR in high-risk patients.⁴  

Advanced imaging such as intra-operative three-dimensional (3D) imaging and the fusion of 3D pre-operative imaging with intra-operative live imaging gives our physicians the confidence they need when handling complex cases. Furthermore, it is a way to reduce the radiation exposure for the patient and the staff.⁵ Radiation exposure is always a concern. Careful monitoring is essential to reducing radiation exposure to both the patient and the team in the hybrid OR. We have found that the Discovery 730 allows for a significant reduction in frame rate while maintaining good imaging characteristics. Experienced centers can now implant aortic valves with <10 minutes of fluoroscopy time.

Read more about the structural heart program in the accompanying article: The Structural Heart Program at Aurora St. Luke’s Medical Center

References

1. Kurra V, Schoenhagen P, Roselli EE, Kapadia SR, Tuzcu EM, Greenberg R, Akhtar M, Desai MY, Flamm SD, Halliburton SS, Svensson LG, Sola S. Prevalence of significant peripheral artery disease in patients evaluated for percutaneous aortic valve insertion: preprocedural assessment with multidetector computed tomography.  J Thorac Cardiovasc Surg. 2009 May; 137(5): 1258-1264. doi: 10.1016/j.jtcvs.2008.12.013.
2. Hybrid operating rooms: with a focus on endovascular hybrid ORs. ECRI Institute, May 2013. Available online at https://www.ecri.org/Forms/Documents/MS13084_HybridOR_Market_Analytics_Snapshot.pdf. Accessed October 22, 2014.
3. Lederle FA, Freischlag JA, Kyriakides TC, Padberg FT Jr, Matsumura JS, Kohler TR, Lin PH, Jean-Claude JM, Cikrit DF, Swanson KM, Peduzzi PN; Open Versus Endovascular Repair (OVER) Veterans Affairs Cooperative Study Group. Outcomes following endovascular vs open repair of abdominal aortic aneurysm: a randomized trial. JAMA. 2009 Oct 14; 302(14): 1535-1542. doi: 10.1001/jama.2009.1426.
4. Adams DH1, Popma JJ, Reardon MJ, Yakubov SJ, Coselli JS, Deeb GM, Gleason TG, Buchbinder M, Hermiller J Jr, Kleiman NS, Chetcuti S, Heiser J, Merhi W, Zorn G, Tadros P, Robinson N, Petrossian G, Hughes GC, Harrison JK, Conte J, Maini B, Mumtaz M, Chenoweth S, Oh JK; U.S. CoreValve Clinical Investigators. Transcatheter aortic-valve replacement with a self-expanding prosthesis. N Engl J Med. 2014 May 8; 370(19): 1790-1798. doi: 10.1056/NEJMoa1400590.
5. Hertault A, Maurel B, Sobocinski J, Martin Gonzalez T, Le Roux M, Azzaoui R, Midulla M, Haulon S. Impact of hybrid rooms with image fusion on radiation exposure during endovascular aortic repair. Eur J Vasc Endovasc Surg. 2014 Oct; 48(4): 382-390. doi: 10.1016/j.ejvs.2014.05.026.