Hybrid technologies have sprung up exponentially in the last several years. As a result of the dramatic development of interventional technology, an increasing number of formerly open surgical procedures can be done in a less invasive manner with catheter techniques or a combination of both open and catheter-based approaches. The need for a professional setting with the high-quality imaging of a catheter lab and the sterility and equipment of an operatiing room has increased. This article first introduces general advantages of hybrid operating rooms, then focuses on specific hybrid procedures like transcatheter aortic valve replacement (TAVR), thoracic endovascular aortic repair (TEVAR), as well as congenital procedures, and concludes with a consideration of future perspectives.

The hybrid concept is an attractive strategy in both the setting and the time. The hybrid operation incorporates advanced imaging technology in an operational suite and integrates techniques of interventional cardiology with those of cardiac surgery. This setting allows a combination of the surgical and interventional components in one procedure, and the patient therefore goes under general anesthesia only once. Performing surgery and intervention during the same course allows the patient to avoid multiple episodes of general anesthesia, which is especially helpful for children and high-risk elderly patients. The hybrid concept incorporates benefits from each discipline, offers the best treatment for each lesion, and also minimizes the invasiveness of the surgery to get the best possible outcome for the patient. The hybrid operating room ensures superior patient safety with high-quality imaging and optimal environment for quick open conversion. The combination of two procedures in one room with just one sedation is not only beneficial for the patient; it is also efficient in the use of operation time and space, and cost-effective. Just one admission is needed, and the teamwork avoids redundant diagnostics and follow-up computer tomography (CT). The time/space efficiency can be life-saving, as well. Preoperative diagnostics for emergencies such as acute aortic dissections can be done in the hybrid operating room to minimize transportation and delay of the surgery.

Figure 1: CT of the Aortic Dissection Type A Limited to the Ascending Aorta (A) 3-D reconstruction of the ascending aorta and aortic arch, (B) Axial view of the dissected part with partial thrombosed lumen distally and (C) Patent false lumen proximally. (D) Fluorscopy of the dissected aorta. CT = computed tomography; 3-D = three-dimensional Figure 2: Fluoroscopy of the TEVAR Procedure (A) Angiography after first stent graft implantation in the ascending aorta, (B) Delivery device with the second stent positioned just next to the origin of the innominate artery, and (C) Final result with partially covered but well perfused innominate artery. Figure 3: Hybrid TEVAR Type 1 Debranching (A) The intraoperative picture shows the ascending aorta with the bifurcated graft to the innominate and carotid artery. (B) The follow-up CT scan with the patent graft and the stent in the aortic arch. TEVAR = thoracic endovascular aortic repair; 3-D = three-dimensional

The hybrid operating room can be applied for operations, which require high-quality imaging. Implantation of a biventricular implantable cardioverter-defibrillator (ICD) can become challenging, and advanced imaging tools and a bailout surgery option should be available. TAVR and interventional mitral valve repair are best performed as an interdisciplinary approach in a hybrid operation room with fluoroscopy, DynaCT, echocardiographic guidance, and a surgeon with a heart-lung machine on standby.

Endovascular aortic repair and peripheral vascular surgery are now done in a hybrid operating room. Often, intravascular ultrasound (IVUS) and transesophageal echocardiography (TEE) are used in addition to fluoroscopy, thus reducing the radiation exposure significantly.¹

Hybrid revascularization, like the minimally invasive direct coronary artery bypass grafting (MIDCAB) plus percutaneous coronary intervention (PCI), is best performed in a hybrid operating room. Pediatric patients are the biggest benefactors from the hybrid concept with a less invasive approach with interventional pulmonary artery stenting and surgical bilateral banding. The high-quality imaging of the hybrid operating room offers the potential to verify pulmonary vessels and validate the surgical result during the operation.

Pacemakers and ICDs, particularly biventricular systems, may be optimally implanted in a hybrid operating room environment because it offers the required superior angulation and imaging capabilities in comparison to mobile C-arms and the higher hygienic standards compared to a catheter lab.

Complications can be better treated, and in the worst case of any heart injury, a conversion to an open procedure can be done without any cutback in hygienic standards or surgical equipment.

The classical hybrid and interdisciplinary procedure is TAVR. In the past 15 years, TAVR has evolved from an experimental, high-risk procedure to a routinely performed, fast-track operation and is now a valid alternative in high-risk patients in whom conventional surgical techniques are considered too invasive and risky. First, it was performed in the catheter lab, but with the increasing numbers and access sites, the operating room has been refitted. The new hybrid operating room creates the best environment with much more space, light, and technology, as well as higher sterility, making the procedure much safer and faster.

Transcatheter techniques are targeting other valves, as well. The mitral valve and the tricuspid valves have already been treated with a transcatheter valve, and valve-in-valve or valve-in-ring procedures have also been successfully performed. With the improvement of the transcatheter technology, several new mitral valve repair devices were developed, such as the MitraClip, Cardioband, or coronary sinus annuloplasty stabilizers. All of these transcatheter procedures need at least fluoroscopic and echocardiographic guidance for positioning and adjusting the devices, as well as the opportunity for a quick open conversion in case of complications like perforation of the atrial wall or MitralClip embolization.

Endovascular aortic repair has evolved in the last decade. Originally, it was used for the abdominal aorta and improved the recovery and early outcome for patients with aortic diseases. With its excellent results and use of the debranching technique, TEVAR was applied more and more proximally to the thoracic aorta, approaching now the high-risk zone "0." In the debranching strategy, the supraaortic branches were bypassed to ensure brain perfusion after coverage of the ostia with an aortic stent graft. TEVAR in zone 0 is used for high-risk patients to avoid repeat sternotomy, cardiopulmonary bypass, and deep circulatory arrest. The hybrid revascularization of coronary arteries combines the best of two worlds. Bypassing the left anterior descending artery with the left internal mammary artery has the best long-term results. Combining this bypass with PCI for the remaining lesions offers a multivessel revascularization through a mini-thoracotomy. Afterwards or perioperatively, the results (especially the bypass) can also be evaluated.

Pediatric patients in particular can benefit from a hybrid operating room and hybrid operations. The stage 1 procedure for the hypoplastic left heart syndrome is one example for a pediatric hybrid procedure. It combines interventional stenting of the ductus arteriosus and surgical banding of the pulmonary arteries. Transcatheter pulmonary valve replacement is another utilization of a hybrid operating room. Next to better imaging, another advantage of the hybrid operation room is the possibility for intraoperative validation of operation results and the pulmonary vessels. The hybrid procedures are less invasive and complex and will lead to fewer adhesions for future operations. The future hybrid operating room will be CT/magnetic resonance imaging (MRI)-based with options for the following: image fusion, integrated IVUS, three-dimensional/four-dimensional imaging, soft tissue visualization, modeling, and navigation. This professional setting will allow very advanced surgical applications.

In conclusion, the hybrid operating room facilitates treatment of a whole spectrum of new cardiovascular therapies. It offers different imaging technology, including fusion options with preoperative CT/MRI data to improve the quality and reduce radiation exposure. Furthermore, it is more spacious and lighter than a normal catheter lab. The interdisciplinary approach maximizes the benefits of each discipline while minimizing the invasiveness of the surgery; the team approach is the optimal strategy to get the best results for the patient.

Reference

1. Kobeiter H, Nahum J, Becquemin JP. Zero-contrast thoracic endovascular aortic repair using image fusion. Circulation 2011;124:e280-2.

Keywords: Anesthesia, General, Angiography, Aorta, Aorta, Abdominal, Aorta, Thoracic, Aortic Diseases, Brachiocephalic Trunk, Brain, Cardiac Surgical Procedures, Cardiopulmonary Bypass, Carotid Arteries, Child, Conversion to Open Surgery, Coronary Artery Bypass, Coronary Sinus, Coronary Vessels, Defibrillators, Implantable, Ductus Arteriosus, Echocardiography, Transesophageal, Emergencies, Fluoroscopy, Follow-Up Studies, Heart Injuries, Heart-Lung Machine, Humans, Hypoplastic Left Heart Syndrome, Infertility, Magnetic Resonance Imaging, Mammary Arteries, Mitral Valve, Operating Rooms, Patient Safety, Percutaneous Coronary Intervention, Pulmonary Artery, Pulmonary Valve, Stents, Sternotomy, Surgeons, Thoracotomy, Tomography, X-Ray Computed, Transcatheter Aortic Valve Replacement, Transportation, Tricuspid Valve

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