The Hybrid OR for Valve Therapy Mathew Williams

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

Disclosures • Consulting: Edwards, Medtronic, Mardil

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

Access Issues • Ability to quickly convert to alternative access: – Retroperitoneal – Subclavian – Transapical – Traditional Surgery

Vascular Injury

Valve Dysfunction

Other Situations • LV perforation • Annular or aortic disruption • Valve misplacement

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

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?

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

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

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

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

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

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

Monitors Multiple Monitors Both sides Accept Several Inputs

Finding Ideal Deployment Angle

Overlay with live fluoro 3 D Contour

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