CLAUDIO GROSSI
Cardiac Surgery
Ospedale Santa Croce
CUNEO (Italy)
INNOVATIONS IN THE
ENVIRONMENT: HOW THE HYBRID
OPERATING ROOM CAN
INFLUENCE CARDIAC SURGERY
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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 Anesthesiologist Emerging Paradigm Anesthesiologist Pa3ent Pa3ent Surgeon Cardiologist Surgeon Cardiologist Reference: Maisano List of Procedures Performed in Hybrid Operating Room
•  Endovascular abdominal aneurysm repair
•  Endovascular thoracic aneurysm repair
•  Hybrid arch reconstruction
•  Transfemoral aortic valve replacement
•  TAVI
•  Trans-subclavian aortic valve replacement
•  Transapical aortic valve replacement
•  Endovascular repair of coarctation of the
thoracic aorta
•  Hybrid coronary revascularization with
coronary angiogram
•  Atrial fibrillation/Flutter ablation
•  Carotid artery stenting/carotid endarterectomy
•  Peripheral vascular stenting
•  Coronary artery
disease
•  Endovascular mitral valve repair
•  Transpulmonary valve replacement
•  Minimal invasive aortic valve /mitral valve
procedures
•  Thoracic aortic
aneurysm
•  Hybrid
therapies for congenital heart diseases
•  Transapical neo-chord replacement for
mitral valve repair
•  CABG procedures
•  Hybrid Maze procedure
•  Atrial septal defect with septal occluder
•  Ventricular septal defect with septal occluder
•  Pacemaker / AICD implantation
•  Neurovascular interventions
•  Interventional bronchoscopy
•  Endoleak coiling
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Transcatheter aortic valve
implantation (TAVI) procedures
Transcatheter aortic valve
implantation (TAVI) procedures
•  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.
Severe intraprocedural complications during TAVI
•  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
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
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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
Aortic Valve Implantation
•  Author: Prof. WaltherGerman
•  Heart Center Leipzig, Germany
Protocol:
• 120 ml contrast media
•  8 min fluoroscopy
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•  Analysis of stent deformation
under implantation allows patientspecific 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.
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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 highrisk 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.
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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
type A dissection with involvement
of the descending thoracic aorta
Class A (absence of ischaemia)
Class B (branch vessel malperfusion)
Class C (circulatory collapse)
Class BC (branch vessel malperfusion
and circulatory collapse)
DeBakey extent II is defined as a
type A dissection with no involvement
of the descending thoracic aorta
Class A (absence of ischaemia)
Class B (branch vessel malperfusion)
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, noninvasive 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:
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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
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