JACQUES KPODONU,MDABS,ABTS,ABVM

Cardiovascular Hybrid OR: The Travelled Road

The Times Are Fast Changing: Are We Prepared?

Patient demand, changing healthcare landscape demand for a new working

environment(Hybrid OR)

Vascular Surgery

.

Plans Equipment Imaging OR table

Key success factors for building an advanced cardiovascular hybrid room:

Clinical Procedure

Requirement Assessment Planning

Project ManagementPartner Management

Cardiovascular Hybrid Operating RoomImaging and surgical equipment in one room

Monitors incl. catheterization

software

3D C-Arm with 80 - 100kW

Sterile environment

OR imaging table e.g. floating table top or traditional breakable OP-

table

Anesthesia equipment

Radiation shielding

Define space based on facility needs address costs Build a functional team including physicians, nurses,

technicians, infection control, environmental services and vendors

Define roles and responsibilities of all parties involved (who owns project coordination) ? Hybrid surgery program director

Decide on imaging equipment and table Define suppliers/vendors for other equipment Always start by identifying imaging equipment location Define all other equipment locations and requirements, i.e.

ceiling lights ,surgical and video integration surgery workflow

Iterative verification of coordination and planning of all vendors in CAD

Reviews of solutions with user group/team (verify that needs are met)

Sign-off concept (vendors and users!!!) Anticipate Future Technologies

Exemplary process in a Hybrid OR Project

Lighting Displays/Monitors

Imaging (Live, Reference, 3D, PACS…) Video Integration (Endo, Ultrasound, Microscope, Navigation….)

Communication and Digital Data Integration Audio (wired, wireless, etc.) Control Room to Operating Room Acoustics

Equipment Reaches especially pendants/utilities Point of use Park positions

Ceiling and Floor Structure Requirements Mass grid option (alignment of all lots!)

Renovation Issues, incl. HVAC and electrical installation Use proper CAD blocks for all equipment and create one single “Masterplan”

Topics to be discussed in Every Hybrid OR Project

Total Investment for Hybrid Operating roomsHoag -$6.7 million

The Road to Hybrid OR – ChallengesPeople and Workflow – It’s a busy place! (room planning)

Plan in 2D Visualize in 3D

OR-Room

Technical-RoomControl-Room

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SurgicalWorkspace

SurgicalWorkspace

Patient

Schematic Room Layout – Important areas for workflow considerations

... and other equipment increases complexity

1. Angiography system2. Contrast injector3. Operating table4. Operating lights5. Anesthesia/respirator/

injectors6. Heart-lung machine7. Ultrasound

(TEE/intravascular ultrasound)8. Surgical instruments /

catheter trolley9. Electrocautery10.Defibrillator11.Cell saver12.IABP13.Ceiling pendants

Cardiovascular Surgery Hybrid Program (Hoag Model)led by endovascular cardiac surgeon

Endoaortic /open aortic surgery program Surgical valve/transcatheter valve program Hybrid maze program Surgical revascularization/hybrid revascularization program Hansen robotic endovascular program)endovascular robotics) Da Vinci robotic surgical program Image guided surgery program MRI /3D CT cardiac imaging program Echocardiography /Intravascular ultrasound imaging program Carotid surgery/ carotid stent program Peripheral vascular surgery program Vascular laboratory program Image guided surgery research program collaboration with Siemens

Phase 1 April 2011

December 2011

December 2011

December 2011

December 2011

December 2011

Phase 5 December 19 2011 $6.7 million

Trans-Catheter Aortic Valve Program:

3D Dyna CT performed in a hybrid OR to accurately size

and deploy trans-catheter valves

procedural details

Endo Aortic Program: CT Fusion Registration for EVAR Guidance In a Hybrid Operating Room

Setting.Preoperative CT scan is exported to the hybrid operating room and fused with a non contrast Dyna CT scan obtained in the operating room .Fusion technology of 2 CT volumes enables real time navigation and placement of sheaths, wires and devices without need for contrast injection.Co registration of IVUS with Fused CT /fluoro images can further decrease use of contrast in renal impaired patients requiring EVAR.

Registration of 3D CT with fluoroscopy with IVUS integration

.A marker is placed perpendicular to the IVUS probe (arrow) on the patient under fluoroscopic guidance to correspond to the location of the renal vessels ostium as determined by IVUS imaging co registered with fusion CT/fluoroscopy.

Endo-Aortic Program: Thoraco-abdominal Endograft.

Hybrid TAAA graft

Fusion CT

1.Endo-Aortic Program: Thoraco-abdominal Endograft

Endo-Aortic Program: Arch-Aorta Endograft.

Arch aneurysm Branched arch endograft

Post repair arch

Courtesy cook Australia

 

 

Possible Future Applications

Image guided minimally invasive surgery

Intraoperative Angiosystem

2D FluoroIntraoperative

3DFunctional

Imaging

Robotics

Image Fusion withMR, CT, US, Endoscopy

Tracking / Navigation

Functional Imaging for CAD (CABG: Pressure, Velocity, FFR)

Rajani R: Eurointervention 2013; 9; 277-83

Functional ImagingPrototype Version – Not commercially available

Blood Velocity VectorsVolumetric Blood Velocity Magnitude

Blood Pressure on Wall

Blood Flow Streamlines

Model automated modeling of mitral valve

*Not commercially available. Due to regulatory reasons its future availability cannot be guaranteed.

automated modeling of aortic valve

*Not commercially available. Due to regulatory reasons its future availability cannot be guaranteed.

Perceptive technology: true understanding of form, flow and function

*Not commercially available. Due to regulatory reasons its future availability cannot be guaranteed.

3D CT mitral valve analysis software for image guide mitral valve surgery/intervention program.

Co-Registration of Data Sets

Fusion of Optics and syngo DynaCT

OUR GOAL: Adding life to years …OUR GOAL: Adding life to years …

In summary: Involve all stakeholders as early as possible in the project!

Discuss layout/concept with all involved parties on hospital and vendor side

Involved parties may be:Scrub nursesBusiness managerPlanning departmentProject ManagerOther vendor representativesSurgeons/interventionalistsTechnical directorHygienistAnesthetist

Questions