Last fall, I visited Vanderbilt University Medical Center in Nashville, Tennessee, and was shown their marvelous hybrid cath lab/OR. An interventional procedure was underway, to be shortly followed by a left internal mammary artery (LIMA) procedure, without moving the patient off the table, just rearranging the equipment to bring the surgical team up to the patient. This “one stop” revascularization procedure was a technological tour-de-force. The concept of combining an operating suite with a cardiac cath lab — a hybrid cath lab [or if you’re a surgeon, a hybrid operatin room (OR)] — is not new, but it has been slow to catch on, probably for some good reasons. Enthusiasm for its use lies in the advancing new percutaneous approaches for aneurysm repair, valve replacements, and shunt closure devices. These novel procedures are proposed to be best delivered in an integrated, hybrid cath lab/operating room that allows both surgical and intravascular procedures to occur sequentially or simultaneously, without moving the patient from one procedure room to another. The rationale for the hybrid room is to overcome the limitations of the separate suites: cath labs have high-quality fluoroscopy equipment, but generally rooms too small for surgery, lacking the sterile requirements and equipment needed for open surgical procedures; ORs have lower quality mobile C-arms not suitable for complex interventional procedures. The hybrid cath lab provides the best of both worlds. Is this the way of the future? Of course, the answer is, “It depends.” It depends on what your major procedure needs and patient types are. The benefit of having both surgical equipment and high-end angiographic equipment is the ability to perform coordinated and specialized, tailored approaches to unique cardiologic problems. Do we need to do combined LIMA and percutaneous coronary intervention (PCI) in the same individual at the same time? Personally, I doubt it, but some situations may certainly warrant such an approach. Consider a patient with critical distal left main (LM) and right coronary artery (RCA) focal 90%. One might make a case of RCA PCI with drug-eluting stent (DES) followed at the same sitting with LIMA, saphenous vein graft (SVG) to the left anterior descending artery (LAD) and circumflex artery (CFX). But do we really need to do both at the same time? Many current similar procedures are being done in separate settings from a staged approach. While the hybrid cath/OR permits surgical and interventional cardiologists to work closer together, it is not clear whether indeed this will lead to better patient outcomes at lower cost. From the hospital viewpoint, the hybrid cath lab also allows hospitals with lower PCI numbers to use the same room to serve the needs of surgeons, thus lowering capital expense. Hybrid labs are ideally suited for procedures that require both percutaneous and surgical interventions, percutaneous valve replacements, deploying percutaneous septal occluders and installing aortic stent grafts. In addition, interventionalists can also be called in after cardiac surgery to perform a completion angiography. However, immediate post-coronary artery bypass graft (CABG) angiography is not well explored and some of the findings may not represent true clinical outcomes due to the acute edema at some graft to native artery acute anastomosis. Potentially, one of the greatest uses of the hybrid cath lab is for pediatric structural heart cases, including treatment for hypoplastic left heart syndrome and shunts. The hybrid lab can also be used in some adult cases, such as pulmonary valve replacement, especially when it is known vessels are too small or tortuous to navigate percutaneously and chest access is needed. When the hybrid is not in use for OR purposes, it can be used as a standard cath lab. Although the hybrid labs increase patient satisfaction, the hybrid is actually less efficient for physicians, who need to coordinate their schedules. On the other hand, patients do not have to plan for different procedures on different days with less time off work. A formal review of the costs for the hybrid lab has not been reported, but there is a time savings for patients and staff, as well as savings in disposables and the costs of set-ups for two procedure rooms compared to one. Finally, the turf war between surgeons and interventionalists may be tempered or even eliminated when both groups coordinate their efforts in one place for a common goal. These mutually beneficial relationships identify more clearly which cases may be better suited for bypass and are referred to the surgeon, and which cases require only angioplasty and can be sent to the interventionalist. The use of a hybrid lab requires a cultural shift, with surgeons moving to less invasive percutaneous alternatives, using aortic stent grafts and implantable heart valves. For many of these new procedures, the percutaneous approach requires surgical arterial access to accommodate 24 French delivery catheters. The surgeon can easily provide secure vascular access through cut down or direct access to the heart, either from a transapical or transthoracic approach. A hybrid lab takes about two or three years to plan and build and costs between $2 and $4 million. Building a lab requires input from not only the interventionalists and surgeons, but also from the nurses, anesthesiologists and hospital infection control staff, to coordinate the room for best use. Hurdles to Hybrids A review from theheart.org1 lists many reasons why hybrid procedures haven’t been widely embraced. Friedrich Mohr (University of Leipzig, Germany), indicated that that surgeons, watching volumes of surgery decline, are more intrigued by hybrid procedures than their interventional counterparts. “There is low interest on the part of the cardiologists [for hybrid procedures],” Mohr told Heartwire. “They would rather do it all themselves than ask a surgeon just to put a LIMA to the LAD.” [Understandably so]. A second and perhaps larger issue is that few surgeons have truly perfected the minimally invasive procedures on enough patients to make the appeal of avoiding a sternotomy a real advantage in the hybrid approach. Another stumbling block is, who owns the lab? One surgeon noted, “It’s partly a turf war and it’s partly logistics.” Other limitations in the hybrid world include the problem of antiplatelet therapy and bleeding risk during surgery. The reimbursement issues have not been fully addressed and are likely not going to be until our national health care is stabilized. Since interventionalists are not reimbursed as fully for a secondary revascularization as they are for performing an isolated procedure, it is unlikely the average interventionalist will adopt this. Insurance carriers may also be a barrier, stating, “Why pay for PCI if you’ve already had surgery at the same time?” From the cath lab point of view, without a special need identified, it is unlikely most interventional cardiologists will dive into the hybrid pool without a substantial push. Nonetheless, we should keep our eyes open for outcomes news in this area.
1. Wood S. Hybrid PCI/CABG procedures: Money, egos, and logistics dampen enthusiasm. October 17, 2005. Available at http://www.theheart.org/article/577673.do. Accessed September 17, 2009.