Hybrid Lab Planning and Perspectives

Is the development of hybrid labs a meaningful trend? Patient need will drive both suite implementation and long-term success. If minimally invasive therapies that combine aspects of cardiovascular surgery, interventional cardiology and most importantly, sophisticated imaging, are helpful in treating patients, then hybrid labs will be here to stay. The entire field is moving towards a convergence between imaging, interventions, and surgery, with the PARTNER (Placement of AoRTic TraNscathetER Valve) trial as one excellent example. There are some hospitals that may end up installing a hybrid lab just to get on the bandwagon. If they have not figured out exactly how the lab will be used, who is going to use it and for what types of procedures, then in those instances, the room may end up being underutilized. What has been your experience at Mayo Clinic? We are now in the process of building hybrid labs. Currently, we have one room in the cath lab where we do combined procedures, but I would not call it a true hybrid suite, although it has some hybrid room characteristics. In this room, we are doing percutaneous aortic valve procedures transfemorally. A second room, within the operating room structure, is where we do transapical aortic valve deployments. Design is absolutely crucial. A regular cath lab is 500 square feet, which is not enough for an anesthesia team, an interventional team, a surgical team, and an imaging team. Each team may have 2-3 people, meaning several individuals and a great deal of equipment have to function smoothly in one space. A regular cath lab or operating room just isn’t big enough. Hybrid labs require a footprint of 900-1,000 square feet minimum to support these types of procedures. The procedures are complex, even though they are minimally invasive. Hybrid labs also require the operating characteristics of both a cath lab and an operating room, and you cannot compromise on either. Sterility, airflow, and the necessary requirements for an operating room cannot be compromised. At the same time, the image quality of the cath lab also cannot be compromised. In other words, you can’t wheel a portable fluoroscopy unit into an operating room and think you now have a hybrid suite. Can you tell us more about your participation in the PARTNER trial and aortic valve replacement? The PARTNER trial is sponsored by Edwards Lifesciences. The purpose of this study is to determine the safety and effectiveness of the Sapien valve and delivery systems (transfemoral and transapical) in high-risk, symptomatic patients with severe aortic stenosis. Our interventionalists and surgeons have a weekly conference in order to select a patient for enrollment. Let me point out that there is no other part of our practice where this type of joint collaboration is currently being done. It needs occur more frequently, even for coronary disease. The surgeon and interventionalist will do their procedures simultaneously, so if it’s a transfemoral, my colleague from surgery will come up from the cath lab, and he and I will work together, along with our teams. The surgeon will do the cut down of the artery, then he or I will put the catheters up. We will cross the valve, deploy the Sapien valve and on the way out, the surgeon will close the wound. The nice thing about having both a surgeon and interventionalist present is that we can each deal with certain complications, should any occur. If there is a coronary embolism, then I can deal with it. If there is any sort of vascular complication, then the surgeon can deal with it. Aortic valve replacement is a procedure that would be very hard to do separately, but together, it can be done very effectively. Similarly, when there’s a transapical case, I will go down to the operating room and work with the surgeon. These are exciting, innovative procedures. I think it is a trend that is here to stay. How frequently are you performing aortic stenosis replacement procedures? We are doing these weekly now. My guess is that it is just going to grow. What about staff? Does the surgeon bring his own and you bring your own? That is what we have been doing. You should never compromise anything. Hybrid room work should enhance your practice, not compromise it. The surgeons have their assistants and their scrub nurses, and I have my cath lab technologist. Everyone on the team is expert at their job, so it is not as though the surgical assistants are trying to learn how to be a cath lab tech or the cath lab tech is trying to learn to be an operating room tech. They already know their jobs and are in their comfort zones, making for a much stronger team. In the future, as these procedures grow, you may have people who are trained in both disciplines, but we don’t have that at present. What has been the impact of all these different disciplines coming together for a single patient? It’s very, very positive. There’s nothing like physical proximity to help facilitate good working relationships between colleagues. That goes for cardiologists, surgeons, or whomever. If you’re actually working side by side with someone, the team-building aspects are much more powerful than if you are just discussing the case, and then going and doing your work separately. What are you working with terms of imaging equipment? In aortic valve replacement, all the valves are placed under imaging. The chest is not open. State-of-the art fluoroscopy is required, along with all sorts of ultrasound —transthoracic, intracardiac or some sort of combination. Imaging is absolutely key, because these are not open procedures. That is a new thing for the surgeons, of course, because they are more used to doing open procedures. It is a learning curve for them in terms of working with image guidance. Manufacturers are offering some interesting new systems. We are using real-time device tracking (Paieon, Israel) to facilitate our TAVI procedures. In general, I think we need to take better advantage of our modern imaging systems to use their full capabilities. Right now, we are able to do what is called a cone beam CT, where you take x-ray technology and rotate it around a patient. The computer can basically reconstruct a CT scan. What about financial reimbursement? These procedures are all investigational right now, although they are covered by Medicare, because I think CMS recognizes their potential for patient care. What do you think about another hybrid procedure, left internal mammary artery bypass grafting of the left anterior descending coronary artery (LIMA-LAD)? It has promise. There are logistical issues to consider. There is a learning curve in terms of doing minimally invasive operations through ports. One of our surgeons, Dr. Suri, has tremendous experience with doing robotically-assisted micro valve repair. Similarly, for the LIMA-LAD, there is a learning curve and we are working with Dr. Daly for that. If you are proposing that drug-eluting stents be placed in the other arteries, then when are you going to do that and how are you going to manage the antiplatelet therapy and chest tube? When do you start the antiplatelet therapy? When do you put the stents in? When do you pull the tube out? These logistical questions need to be worked out. Perhaps if they are not done simultaneously, they can be done sequentially. As hospitals look to create a hybrid suite, what should be the focus? Hospitals need to think through how they are going to use this equipment before they go out and buy it. They need to consider their patient population, volume, and which specialties will be using these suites. The imaging requirements for an endovascular lab doing abdominal aortic aneurysm repair may be different than a hybrid lab putting in aortic valves. A very large hospital, in a large urban area, may require multiple hybrid suites; perhaps each specialty gets their own. On the other hand, if you’re a community hospital and you can only afford one, you have to design something that will work for 3 or 4 specialties. Dr. Rihal can be contacted at rihal@mayo.edu