Physical Address

304 North Cardinal St.
Dorchester Center, MA 02124

Building a Hybrid Operating Suite Including Robotic Capability


One of the fastest-growing developments in interventional cardiovascular medicine is the development of the hybrid suite. These are constructed either in a traditional operating room or catheterization laboratory (“cath lab”) environment, thereby permitting a combination of both open and catheter-based procedures. Although hybrid rooms were developed largely to support vascular surgeons, there has been rapid expansion of hybrid room use into other cardiovascular services. Some rooms are now designed by surgeons, others by cardiologists; some, as is most appropriate, are designed by both. For example, the first hybrid room was built at Houston Methodist Hospital in 2008 to support the development of advanced vascular procedures, especially hybrid aortic procedures. However, the hospital's most recently constructed room has designated days for dealing with percutaneous aortic valves and has been used extensively for hybrid coronary revascularization, atrial appendage ligation, laser lead extraction, and an increasing variety of vascular procedures. Furthermore, the advanced imaging capabilities of these new rooms, especially cone-beam computed tomography (CT) and image fusion capabilities, promise to revolutionize how all of these procedures are performed.

In reality, it makes no sense not to be able to switch between open and endovascular therapies. The primary limitations have been traditional turf issues, meaning that cath labs and interventional suites “belonged” in cardiology and radiology, respectively. Those barriers are rapidly being broken down, with renewed emphasis on the most minimally invasive but appropriate approach for the benefit of the patient. We believe that the cone-beam CT capabilities of modern imaging systems can transform surgery and are now performing lung nodule localization for thoracic surgeons using techniques developed for translumbar embolization. A “CT scanner” in the operating room is as empowering as the initial angio-equipped portable C-arm, which led vascular surgeons into the minimally invasive world.

However, hybrid suites should best be defined by their purpose. That purpose, we submit, is to provide a seamless transition from open to endoluminal procedures and, most importantly, to select the most appropriate therapy for the disease process being treated. Consequently, when defining the hybrid suite concept, clear agreement on the proposed role of the suite, appropriate consultation for adjunctive equipment, and a rigorous planning process are necessary to avoid disenfranchisement and costly construction mistakes. There are no established guidelines for the development of a hybrid suite. In this chapter, we review the roles of such a suite, the planning process, financial models, and appropriate case selection.

Planning a Hybrid Room

Planning and construction of a hybrid room is a complex process, governed by regulatory requirements, room dimensions, power availability, heat dispersal capabilities, and structural requirements to support the heavy imaging apparatus. This all must occur before construction and installation of the imaging system even begins. Mistakes are expensive and difficult to remedy. Having worked through this process now on several occasions, we are able to provide a guide for those planning to place an interventional suite within an operating suite. This is meant to be a very practical guide, with checklists, financial estimates, and a discussion of the problems we have encountered. We have tried to do the following:

  • 1.

    Define the concept of a hybrid suite and describe the major components and equipment capabilities of a successful suite.

  • 2.

    Document the construction steps and permissions necessary to proceed with the suite.

  • 3.

    Explain costs and reimbursement potential of a hybrid suite and utilization requirements.

  • 4.

    Present aortic, coronary, and ablation cases that can most appropriately benefit from a hybrid approach.

Do You Need a Hybrid Room?

First you must ask whether you really want to do this. What are the advantages and disadvantages? In our opinion, a hybrid room is absolutely necessary for a modern cardiovascular service line. It is necessary for the performance of cutting-edge procedures, which rapidly become contemporary procedures, and to recruit and retain the best interventionalists (a word we use in its broadest terms). However, all hybrid rooms are not the same, and the very word hybrid conjures up a variety of interpretations to cardiologists, surgeons, and administrators alike. At present it is clear that the renewed wave of enthusiasm for hybrid room has been engendered by the approval of percutaneous aortic valves. In Europe, many of these procedures are conducted in a cath lab that has been upgraded to permit surgical interventions if they are absolutely necessary. This is hardly ideal for performing an emergency surgical procedure.

In our opinion, the ideal setting is a cath lab. What we describe here is a room that can easily accommodate major open cardiac and vascular procedures in addition to endovascular interventions. There is no doubt that an institution can “make do”; indeed, finances and physical plant may dictate that. What we are describing is the optimal situation, which provides the best environment regardless of approach. The hybrid room in our organization is where imaging, navigation, and robotics all come together. Many of the interventions currently requiring surgical access or a surgical component may well evolve to be totally percutaneous. That is the natural history of an endovascular procedure. However, interventions not yet even imagined will be introduced, and many of these early-phase procedures will be most appropriately performed in a hybrid room. Thus hospitals will need an increasing number of hybrid rooms for the foreseeable future.

Where Should You Build the Hybrid Room?

The issue then is not so much whether you need a hybrid room, but whether you want it to be in the operating room or the cath lab. There are clearly many advantages and disadvantages to both ( Table 45.1 ). Ultimately the ideal setup is to colocalize the cath labs, operating rooms, and the hybrid rooms. For new facility construction, we believe this is the optimal arrangement for a cardiovascular service line. However, for most organizations, this is not feasible and a decision on where to place the hybrid room must be made. The first question often asked is, “Can I easily convert a preexisting operating room or cath lab?” The answer is probably not, and certainly not easily. Creation of such a space in an established operating room can present considerable challenges. Preexisting rooms are often too small, may not be lead-lined, or may have inadequate air-handling capabilities. However, a combination of two rooms or operating rooms with adjacent storage space for a control room can be considered.

TABLE 45.1
Pros and Cons of Planning a Hybrid Room in a Cath Lab Versus the Operating Room
Cardiac Catheterization Lab Operating Room
Staff familiar with fixed C-arm imaging system Staff less familiar with imaging, perhaps mobile C-arms
Staff less familiar with open surgical procedures Staff familiar with open surgical procedures
Rapid turnover, more conscious sedation procedures Relatively slow turnover, more general anesthesia procedures
Lead-lined walls May or may not have lead-lined walls
Staff aware of radiation safety measures Relatively less radiation safety aware
With or without anesthesia gas support With anesthesia gas support, mechanical circulatory support
Layout designed for catheter angiography Layout designed for open surgery (HVAC)
Ceiling struts in place, may not have laminar airflow Located in sterile core with laminar airflow
Smaller rooms (not necessarily close to PACU) Relatively larger rooms (with proximity to PACU)
Availability and staff familiarity with endovascular devices Staff more familiar with open surgical instruments
Staff familiar with cardiac hemodynamic monitoring systems Patient monitoring by anesthesiologists
HVAC , Heating/ventilating/air-conditioning; PACU , perioperative anesthetic care unit.

The second and more common question is, “Should this be built in an operating room suite or a cath lab suite?” Typically, for the reasons outlined in Table 45.1 , the operating room is the preferable environment. In our experience, this then sets in motion a series of issues that must be addressed. First is the understanding that this room does not “belong” to the surgeons. Procedures should be prioritized based on the most appropriate use of the facility, with no particular preference to any specific user group ( Box 45.1 ). In our organization, we have set aside Wednesdays for percutaneous aortic valve procedures with the expectation that this need will increase. This is an organizational decision based on strategic priorities for the heart and vascular center. All other days have an open booking system wherein cardiologists and surgeons are treated equally. Although the hybrid room is located within the operating suite, it is extremely important that the cardiologist and the cath lab staff are welcomed, empowered, and not treated as second-class citizens. That message must come from surgical and cardiology leadership combined. The room is part of our heart and vascular center and is not owned by any particular group.

Box 45.1
Procedures Performed in the Hybrid Room

Highly Appropriate

True hybrid procedures (open surgical and endovascular)

  • Aortic debranching and endografts

  • Retroperitoneal access and conduit for endograft delivery

  • MICS CABG with completion coronary angiogram or intervention

  • MICS AFib—combined transpericardial and endovascular approach

  • Left atrial appendage exclusion

  • TAVR with transapical, direct aortic, or minithoracotomy access

  • Remote live-case broadcasting

  • Complex endograft (FEVAR, ChEVAR) procedures

Moderately Appropriate

  • Abdominal endografts (EVAR)

  • Thoracic endografts (TEVAR)

  • Total occlusions (iliofemoral, venous)

  • Percutaneous valve procedures (TAVR, TMVR)

  • Venus recanalization procedures

Less Appropriate

  • Percutaneous diagnostic angiograms and interventions

  • Laser lead extraction procedures

AFib , Atrial fibrillation; CAB , coronary artery bypass; ChEVAR , chimney endovascular aortic repair; FEVAR , fenestrated endovascular aortic repair; MICS , minimally invasive cardiac surgery; TAVI , transcatheter aortic valve implantation; TAVR , transcatheter aortic valve replacement; TEVAR , thoracic endovascular aortic repair; TMVR , transcatheter mitral valve repair.

You're Reading a Preview

Become a Clinical Tree membership for Full access and enjoy Unlimited articles

Become membership

If you are a member. Log in here

Related Posts