The Structural Heart Program at Aurora St. Luke’s Medical Center

Aurora St. Luke’s Medical Center in Milwaukee, Wisconsin opened its first hybrid OR room to the public in a grand opening on August 5, 2014. The room was sterilized and in use for procedures the next day. A second hybrid room opened about a week later.

Read more about the hybrid rooms at Aurora St. Luke's Medical Center in the accompanying article: The Hybrid OR: A Lot to Love.

When did the structural heart program at Aurora St. Luke’s Medical Center first begin?

We first formed our heart team focusing on valve therapy in 2006 as we prepared for the EVEREST I feasibility trial of the MitraClip (Abbott Vascular). At that time, and until recently, we had used a large cath lab where surgical and cardiology teams worked together. We experienced steady growth in our case volume and when we began the U.S.  Pivotal Trial for Corevalve (Medtronic), the Sapien valve (Edwards Lifesciences) gained FDA approval. We have experienced dramatic increases in our transcatheter valve cases and surgical cases. This year, we are at a pace to implant well over 200 aortic or mitral devices using catheter-based techniques. Because of this accelerated growth we, have opened two new hybrid operating rooms. We partnered with GE Medical for this construction and we are using the GE Discovery IGS 730 for imaging.

What do you like about the Discovery system?

The major advantage is that we can have the C-arm near the table when we need it and move it away completely when we don’t need it. We are not burdened by working around a fixed C-arm. It allows us to do more complex procedures with multiple specialists. Another feature we like is that the highly adjustable frame rate allows us to significantly reduce radiation exposure and still have excellent imaging. 

The Discovery is laser guided. What does that mean?

The system can be removed away from the table and has a number of preset positions that it can move to within the room. For example, if we are doing a case and we need to get it out of the way in a hurry, there is a bailout button that will retract the system and it will park itself into a corner of the room. The system is guided by a laser on the top of the equipment to move itself around the room safely, under our direction, to preset locations that we can choose off a menu. The location of the IGS 730 is variable depending on the procedure being performed and the access which is needed.

Can you tell us more about the procedures you are doing in the hybrid rooms?

Our team is doing thoracic endovascular aortic aneurysm repair (TEVAR), routine and complex abdominal aortic aneurysm repair (EVAR), patent foramen ovale (PFO) closure, complex endoscopic epicardial and endocardial ablation for atrial fibrillation, MitraClip (Abbott Vascular) and, of course, a large volume of transcatheter aortic valve replacement (TAVR).

This year at TCT, we presented a very complicated case that demonstrated the simultaneous use of fluoroscopy and echo to place a transcatheter aortic valve.

This is obviously a huge part of our program and we have done up to 10 TAVR cases in a week, but more typical is 5 TAVR cases each Monday. We just started doing robotic-assisted mitral valve repair in the hybrid room with the da Vinci robotic surgical system (Intuitive Surgical). It is another minimally invasive valve therapy that requires placing cannulas and equipment that needs fluoroscopy for proper placement. That has worked very well for us.

What imaging is in use during a TAVR procedure?

The valve is deployed under fluoroscopy. We use fluoroscopy to obtain and confirm our positions. Echo is mostly used to look at the heart one more time before we implant to make sure everything is as expected.  At the end, we use echo to assess how well the valve is working and to establish if there are any leaks or problems related to malposition. We have used echo for sizing, but generally patients are sized with computed tomography (CT) angiography. Recently, we have also been working with intracardiac echo (ICE) to see if those images may be more advantageous for us. 

This year at TCT, we presented a very complicated case that demonstrated the simultaneous use of fluoroscopy and echo to place a transcatheter aortic valve. The patient was sent to us from another institution where she had a previously placed bioprosthetic valve in the mitral position. One of the struts from this valve was obstructing the left ventricular outflow tract just millimeters below the aortic annulus. Now the patient had developed severe aortic stenosis and this strut made TAVR a potentially challenging option. With the use of simultaneous echo and fluoroscopy, a CoreValve (Medtronic) was placed so we could get a perfect landing down to the millimeter. We were looking at both modes simultaneously, one screen next to the other, allowing us to see the strut very well on the echo and see the position of the CoreValve very well with fluoroscopy. It went beautifully. The patient did very well. That was presented in the challenging cases section at the 2014 TCT meeting.

It is unusual that Aurora St. Luke’s Medical Center chose to build two hybrid rooms. Most centers have just a single room. Sometimes it can be tough in terms of scheduling.

It is a huge advantage. I am still learning how special this is. We have some people coming to watch from around the country. There is a great deal of interest, because the two rooms have allowed us to safely and efficiently treat a large number of patients in a short period of time. Yesterday we did five TAVR cases. We started at 7:30am and we were done by 2:30pm. Just to give you some perspective, many of the centers I visited are only able to complete two cases in a day. Our system utilizes cross-training and teamwork, and the result has more than doubled our productivity.

TAVR is labor intensive and we aim to make the best use of our resources. Over the next few weeks, we will have visitors from around the country and as far away as France coming to study our efficiency.

Read more about the hybrid rooms at Aurora St. Luke's Medical Center in the accompanying article: The Hybrid OR: A Lot to Love.