How the Hybrid Operating Room Can Influence Cardiac Surgery

CLAUDIO GROSSI

Cardiac Surgery Ospedale Santa Croce CUNEO (Italy)

INNOVATIONS IN THE ENVIRONMENT: HOW THE HYBRID OPERATING ROOM CAN INFLUENCE CARDIAC SURGERY

Impossibile visualizzare l'immagine. La memoria del computer potrebbe essere insufciente per aprire l'immagine oppure l'immagine potrebbe essere danneggiata. Riavviare il computer e aprire di nuovo il ﬁle. Se viene visualizzata di nuovo la x rossa, potrebbe essere necessario eliminare l'immagine e inserirla di nuovo. The hybrid surgical suite

Basic equipment and design of the hybrid endovascular operating room

§ A fully integrated interventional hybrid operating room combines: Ø high level surgical sterility Ø flat-panel cardiovascular imaging, Ø a linked workstation with post processing and storage facilities § The imaging system must provide superior image quality, higher tube heat capacity

Imaging techniques in the hybrid operating room

• Rotational angiography is a medical imaging technique based on x-ray, that allows to acquire CT-like 3D volumes using a fixed C-Arm. • The fixed C-Arm thereby rotates around the patient and acquires a series of x-ray images that are then reconstructed through software algorithms into a 3D image. • Commercial name for Siemens is DynaCT Imaging techniques in the hybrid operating room

• Rotational angiography versus angio CT

• The patient positioning on the CT scanner table differs from the positioning on an interventional table during hybrid surgery, • Intraoperative 3D imaging with rotational angiography is much more precise and can be performed with rapid ventricular pacing. Advanced visualization in the hybrid operating room

Examples of syngo DynaCT Cardiac

Segmentations: Left atrium (red), Aorta (blue), Esophagus (green)

Segmented left atrium Segmented aortic root with landmarks. • The definition of hybrid procedures in the literature varies widely. • A strict definition of a hybrid procedure is a major procedure that combines a conventional surgical part including a skin incision • Wider definitions include procedures where the interventional and surgical parts are done in sequence • In generally we can speak about hybrid procedure anytime we cumulate some kind of diagnostic and therapeutic intervention. Multidisciplinary Cardiovascular Team

Old Paradigm Emerging Paradigm

Anesthesiologist Anesthesiologist

Paent Paent

Surgeon

Cardiologist Cardiologist Surgeon

Reference: Maisano List of Procedures Performed in Hybrid Operating Room

• Endovascular abdominal aneurysm repair • Endovascular repair of coarctation of the • Endovascular thoracic aneurysm repair thoracic aorta • Hybrid arch reconstruction • Hybrid coronary revascularization with coronary angiogram • Transfemoral aortic valve replacement • Atrial fibrillation/Flutter ablation • Trans-subclavian• aorticTAVI valve replacement • Carotid artery stenting/carotid endarterectomy • Transapical aortic valve replacement • Peripheral vascular stenting • Endovascular• mitral Coronary valve repair artery disease • Minimal invasive aortic valve /mitral valve • Transpulmonary valve replacement procedures • Transapical neo-chord• Thoracic replacement for aortic • Hybridaneurysm therapies for congenital heart diseases mitral valve repair • Pacemaker / AICD implantation • CABG procedures • Neurovascular interventions • Hybrid Maze procedure • Interventional bronchoscopy • Atrial septal defect with septal occluder • Endoleak coiling • Ventricular septal defect with septal occluder

• Joint recommendations of the ESC and the EACTS consider the hybrid operating room the optimal environment for these new therapeutic options

• In Germany, joint recommendations of the German Society of Cardiology and the German Society of Cardiac, Thoracic and Vascular Surgery demand a hybrid operating room or hybrid cathlab as a prerequisite for a TAVI program. e Cardiac Hybrid OR A Platform for Collaboration

Hybrid OR is the temple of “Heart Team” • An interdisciplinary approach to TAVI facilitated bailout procedures accomplishing acceptable outcomes, despite severe intraprocedural complications. • These bailout manoeuvres in potentially fatal complications were only accomplished through an interdisciplinary heart-team effort, creating a surgical and interventional safety net, which should be established in all centers performing TAVI Severe intraprocedural complications during TAVI procedures. • The use of cardiopulmonary bypass enhances safety in critical transcatheter aortic valve implantation procedures. • Furthermore, transcatheter aortic valve implantation with cardiopulmonary bypass seems to provide better results than medical therapy or conventional aortic valve replacement in critically ill patients. • The need for cardiopulmonary bypass emphasizes that the procedure should be performed only in cooperation between cardiologists and cardiac surgeons. Advanced visualization in the hybrid operating room

• Aortic root assessment using perioperative DynaCT imaging during transcatheter aortic valve implantation Impossibile visualizzare l'immagine. La memoria del computer potrebbe essere insufciente per aprire l'immagine oppure l'immagine potrebbe essere danneggiata. Riavviare il computer e aprire di nuovo il ﬁle. Se viene visualizzata di nuovo la x rossa, potrebbe essere necessario eliminare l'immagine e inserirla di nuovo.

Conclusions: • Optimizing implant angles may be important in reducing paravalvular regurgitation. • This is significantly more likely to be achieved with AVG rotational angiography. Advanced visualization in the hybrid operating room

• syngo DynaCT Protocol: Aortic Valve Implantation • Author: Prof. WaltherGerman • 120 ml contrast media • Heart Center Leipzig, Germany • 8 min fluoroscopy Impossibile visualizzare l'immagine. La memoria del computer potrebbe essere insufciente per aprire l'immagine oppure l'immagine potrebbe essere danneggiata. Riavviare il computer e aprire di nuovo il ﬁle. Se viene visualizzata di nuovo la x rossa, potrebbe essere necessario eliminare l'immagine e inserirla di nuovo.

• Analysis of stent deformation under implantation allows patient- specific simulation of the leaflets mechanics to assess coaptation Coronary artery disease

Coronary artery disease: Hybrid procedure

• Revascularization of the left anterior descending artery with the left internal mammary artery is by far the best treatment option in terms of long term results. • The LIMA-LAD graft may be responsible for the majority of the benefit of CABG surgery. • Minimally invasive CABG surgeries reduce the procedure related comorbidities. Coronary artery disease: Hybrid procedure

• Hybrid coronary revascularization, combining the LIMA-LAD graft and DES to non-LAD vessels, might become a very good revascularization alternative in multivessel CAD. • In hybrid OR we are able to perform a simultaneous approach, checking the result of surgical graft and completing revascularization in a single procedure • This “one stop” approach improves efficiency and reduces cost, and it may also help to reduce the risks associated with patient transfers and handoffs.

• We believe that widespread initiation of a successful hybrid program hinges on the adoption of a multidisciplinary approach to hybrid thinking, with good collaboration between interventional cardiologists and cardiac surgeons. • Furthermore, it is critical that the expertise of both parties is comparable because implementing hybrid practice in a center more experienced in 1 revascularization modality than the other could be detrimental

Hybrid coronary procedure: when?

• YES if: Ø It is always an option for patients unsuitable for conventional surgery. Ø Patients with comorbidities that make preferable a minimally invasive CABG compared to classic sternotomy approach, including previous cardiac surgery Ø Patients in which is not possible to use both mammary arteries Hybrid coronary procedure: when?

• NO if: Ø Patients are in unstable clinical situation / urgent revascularization Ø Patients not suitable for mini-chest left side access Ø Patients in which you plan a complete arterial revascularization or at least two mammary arteries Ø Patients with previous restenosis on DES or with high probability of restenosis after DES Ø There is a contraindications to dual antiplatelet therapy or PTCA • The postoperative outcomes using combined SYNTAX and the euroSCORE stratification showed: Ø a similar rate of the composite endpoint for all groups except for patients with ≥ 33 SYNTAX/> 5 euroSCORE Ø (0% for the coronary artery bypass grafting group vs 33% for the hybrid coronary revascularization group, P = .001) Ø In patients with complex coronary disease CABG might offer superior 30-day outcomes. Impossibile visualizzare l'immagine. La memoria del computer potrebbe essere insufciente per aprire l'immagine oppure l'immagine potrebbe essere danneggiata. Riavviare il computer e aprire di nuovo il ﬁle. Se viene visualizzata di nuovo la x rossa, potrebbe essere necessario eliminare l'immagine e inserirla di nuovo.

Thoracic endovascular aortic repair (TEVAR) Thoracic endovascular aortic repair (TEVAR)

• Currently, the treatment of complex thoracic aneurysms is mostly endovascular • A combination of surgical and endovascular treatment is reserved for a highly selected group of patients who are too high- risk for surgical open repair and have inadequate length of the landing zone (distal or proximal) for deployment of endovascular stenting • Hybrid arch procedures provide a safe alternative to open repair and extend the indication of the approach to this high-risk cohort with midterm survival outcomes similar to those for the open total arch procedure. • For younger patients with fewer comorbid risk factors and with exclusion criteria to hybrid arch repair, the open total arch procedure remains a reasonable option. Impossibile visualizzare l'immagine. La memoria del computer potrebbe essere insufciente per aprire l'immagine oppure l'immagine potrebbe essere danneggiata. Riavviare il computer e aprire di nuovo il ﬁle. Se viene visualizzata di nuovo la x rossa, potrebbe essere necessario eliminare l'immagine e inserirla di nuovo.

Acute type A aortic dissection The Penn integrated classification of acute type A aortic dissection

Extent of acute type A dissection Clinical presentation of acute type A dissection DeBakey extent I is defined as a Class A (absence of ischaemia) type A dissection with involvement of the descending thoracic aorta Class B (branch vessel malperfusion) Class C (circulatory collapse) Class BC (branch vessel malperfusion and circulatory collapse) DeBakey extent II is defined as a Class A (absence of ischaemia) type A dissection with no involvement Class B (branch vessel malperfusion) of the descending thoracic aorta Class C (circulatory collapse) Class BC (branch vessel malperfusion and circulatory collapse) • In acute type A dissection (AAAD), it is commonly decided to carry out immediate surgical repair without invasive diagnostics. • The hybrid operating room (Hybrid OR) concept encompasses simultaneous haemodynamic control, non- invasive and invasive diagnostics and immediate surgical and/or interventional treatment. • The Hybrid OR concept enables the exact diagnosis of coronary status and downstream malperfusion sites and influences the design of surgical and/or endovascular treatment, without time delay and at negligible risk to the patient The Hybrid OR concept in acute aortic dissection Ø a 24-hour “Aortic Team” was set up, consisting of cardiac surgeons, cardiologists and cardiac anaesthesiologists. Ø Haemodynamic and pulmonary monitoring and preparation for surgery are carried out simultaneously The Hybrid OR concept in acute aortic dissection Ø In cases of tamponade, sternotomy and staged release of pericardial tension by controlled drainage are carried out first. If the patient’s condition stabilizes, angiography is performed Ø Four potential malperfusion sites (coronary, cerebral, visceral and peripheral vascular branches) are studied for strategic planning. Ø In selected cases, control angiography follows surgery to confirm the distal perfusion situation. In the event of ongoing malperfusion, additional endovascular interventions ensue. Hybrid OR concept - consequence of new diagnostic approach: § A third of patients also had concomitant descending thoracic aortic reconstruction with a frozen elephant trunk technique. § A third of patients who underwent cardiac catheterization required coronary artery bypass grafting. § A fifth of patients who completed preoperative angiography Ø We observe a trend towards a better required endovascularsurvival rate intervention after endovascular to address visceral and peripheral malperfusionperfusion repair syndromes prior prior to to central aortic repair. § Persistent malperfusioncardiopulmonary after central aorticbypass repair was evaluated immediately with angiography and resulted in five additional endovascular procedures. • The Essen concept demonstrates the possibility of individualized management for acute type A aortic dissection based on the Penn classification because advanced diagnostics and therapeutics can be performed without delay in a single clinical venue.

• The major change in theoretical approach inside Hybrid Operating Room is cultural: you should start thinking not only in what has already be done but also to what could be better performed

• This means the possibility of adding new therapeutic possibilities inside the the integrated heart team to benefit our patients in a context of maximum safety

• The next step will be the measurement of those benefits Impossibile visualizzare l'immagine. La memoria del computer potrebbe essere insufciente per aprire l'immagine oppure l'immagine potrebbe essere danneggiata. Riavviare il computer e aprire di nuovo il ﬁle. Se viene visualizzata di nuovo la x rossa, potrebbe essere necessario eliminare l'immagine e inserirla di nuovo.