Hybrid Room Research Articles

280. VATS (Video Assisted Thoracoscopic Surgery) with radiological guidance in hybrid operating room: Technique standardization, organizational aspects and dose optimization

Purpose The aim of this work was to optimize the Video Assisted Thoracoscopic Surgery (VATS) procedure through a new rotational geometry avoiding also the interference of the flat panel with infusion lines, vital monitoring equipment and intubation instrumentation. Methods The VATS technique was performed in the Hybrid Room environment that can be used at the same time as a diagnostic room and a surgical room. The C-Arm robotic angiography acquires cone beam CT with reduced angle rotation around the patient permitting the lateral decubitus access to thoracic surgeons with two different protocols: 12sDCTLargeVolume (12s) and 5sDRBODYCARE (5s). The first one allows to scan large volumes by twisting twice around the patient. The second protocol allows to shrink the field to the region of interest with a single pass. Organ dose and REID (Risk of Exposure-Induced Death) were estimated with Monte Carlo methods in PCXMC. Results The initial and final positions of the C-Arm rotation were changed from −170, +30 to −100, +100 in the 5s protocol reducing the risk of collision in case of critical cases (external lesions), wherever the bed is located. After optimization we reduced the dose of 80% in the 12s protocol and of 8.5 times in the 5s. the organ dose and REID are shown in the table. Conclusions VATS is a rapidly emerging surgical technique for the excision of lung nodules that permits to perform radical surgery of lung cancers to a larger cohort of patients and with a longer expectancy of life respect to conventional surgery. We optimized the protocol by changing rotational departure and arrival position avoiding collisions and reducing the dose.

The use of pre-caesarean prophylactic intra-arterial balloon catheters for suspected placenta accreta.

The incidence of placenta accreta (PA) has markedly increased in the United States, from 1/30000 in 1950 to 1/731 deliveries in 2011. Although placenta praevia after prior caesarean sections (CS) is the most important risk factor for PA, other risk factors make up 1-5% of PA occurrences. At our referral hospital, we use the pre-caesarean prophylactic balloon catheter with or without post-surgery embolisation in a hybrid room. Here, we evaluate the role of prior CS and placenta praevia on the outcome of this procedure. This retrospective cohort analysis included 61 women during the years 2004-2016 with sonographic suspicion of PA who underwent balloon catheterisation prior to CS. Eleven women had no previous CS (18%). Mean previous CS rate was 1.85. Six women (9.8%) had previous dilatation and curettage (D&C); 36.4% of women with no previous CS had previous D&C compared with 4% of women with previous CS (P=0.008). Placenta praevia was sonographically diagnosed in 55 women (90.2%). There was a higher rate of caesarean hysterectomy in women with previous CS than in those without (32% vs 0%, P=0.052) but no significant difference in blood product requirements (45.5% vs 66%, P=0.303). There was no significant difference in hysterectomy rate, blood transfusion or surgery duration between women with and without placenta praevia (P=0.648, 0.594, 0.995, respectively). Previous CS rather than placenta praevia is a strong indicator of hysterectomy in cases of PA. Different risk factors for PA do not affect blood transfusion rates or surgery duration.

Radiation Dose Reduction During EVAR: Results from a Prospective Multicentre Study (The REVAR Study)

To evaluate radiation exposure in standard endovascular aneurysm repair (EVAR) using intra-operative guidance with pre-operative computed tomographic angiography (CTA) fusion and strict ALARA guidelines in a modern hybrid room. Between February and November 2016, consecutive patients with AAA undergoing EVAR with a bifurcated device in a hybrid room under fusion imaging guidance were prospectively enrolled in six aortic centres from the United States (n = 1), Europe (n = 4), and Japan (n = 1). Demographic data including body mass index (BMI), indirect dose area product (DAP), cumulative air kerma (CAK), variables influencing dose delivery, and contrast media volume were collected. 85 patients (90.4% males) were included. The median age was 75 (IQR 69–81), with a median BMI of 27.4 (IQR 24.7–30.6). Median DAP and CAK were 14.7 (IQR 10.0–27.7) Gy·cm2 and 107 (IQR 68.0–189.0) mGy, respectively. The median contrast volume was 47 mL (IQR 35–70) (equivalent to 14.1g of iodine [IQR 10.5–21.0]). Median DAP per centre was 28.1 (n = 16, IQR 12.6–47.1), 15.9 (n = 11, IQR 11.9–22.5), 14.2 (n = 12, IQR 10.9–25.7), 20.2 (n = 18, IQR 7.0–39.5), 10.3 (n = 27, IQR 8.2–14.7) and 26.5 (n = 1) Gy·cm2. In multivariable analysis, collimation was the only factor that was significantly associated with DAP reduction, (coefficient = −0.014 per percentage of collimation, 95% CI −0.019 to −0.008, p < .001). With adherence to the ALARA principle and routine application of fusion imaging guidance for EVAR, low radiation exposure compared with the published literature can be achieved in a real world setting.

Preoperative Dye Localization for Thoracoscopic Lung Surgery: Hybrid Versus Computed Tomography Room

Preoperative computed tomography (CT)-guided dye localization is essential for the surgical treatment of small lung nodules and is mostly performed by radiologists in the CT room. Several studies reported their early experiences of preoperative localization in the hybrid operating room. A comparison between localization in the CT room and hybrid room has not been reported. Therefore, we compared the outcomes of preoperative localization in the hybrid and CT rooms. This study included patients who underwent preoperative CT-guided dye localization for thoracoscopic lung tumor surgery in the hybrid operation room (n= 25) and CT room (n= 283) at our institute. Propensity matched analysis, incorporating nodule size, number, and depth, and operation method, was used to compare the short-term outcomes of these two groups. Each patient in the hybrid room group was matched with 2 patients in the CT room group. Localization was successfully performed in 23patients (92%) and 50 patients (100%) in the hybrid room and CT room groups, respectively. There was no significant difference in demographics between groups. In the hybrid room group, the global time was shorter (192.6 versus 244.1 minutes, p= 0.003), and the localization time was longer (33.1 versus 22.3 minutes, p < 0.001). All lung nodules were successfully resected in both groups, but the hybrid room group had a relatively higher morbidity rate. The hybrid operating room may be associated with a shorter global time and similar perioperative and postoperative outcomes compared with the CT room. Localization in the hybrid operating room seems an effective alternative method for managing small lung nodules.

Multicenter Experience in Translumbar Type II Endoleak Treatment in the Hybrid Room With Needle Trajectory Planning and Fusion Guidance

The objective of this study was to evaluate the efficacy of treating type II endoleaks (T2Ls) after aortic endovascular repair with image guidance translumbar puncture using intraoperative cone beam computed tomography with preprocedure computed tomography angiography fusion in hybrid operating rooms. There were 26 consecutive T2L patients in three different institutions treated between March 2015 and September 2017 using direct translumbar puncture of the abdominal aortic aneurysm (AAA) sac after previous endovascular aortic repair. All patients were treated at a single setting using a needle trajectory planning and guidance software (Needle ASSIST; GE Healthcare, Chicago, Ill). All patients (n = 26; 19 men, 7 women; age range, 59-95 years; mean body mass index, 27.44 ± 3.06 kg/m2) underwent treatment for AAA sac expansion or symptoms. Four patients had failed to respond to previous catheter-directed T2L treatment. Time to initial endoleak diagnosis ranged from 2 to 1914 days (average, 404 days). Aneurysm size after initial repair was 60.27 ± 7.5 mm; sac size had increased 10.12 ± 6.5 mm at the time of treatment. Onyx (ev3, Covidien, Plymouth, Minn) or glue (n-butyl cyanoacrylate) and coil embolization were used in 20 of 26 cases; 6 patients were treated with coiling alone. Total procedure time was 75.9 ± 40.7 minutes, contrast material volume was 19.9 ± 29 mL, fluoroscopy time was 13.74 ± 12.2 minutes, and radiation dose was 121.16 ± 167.7 mGy. After embolization, the mean sac diameter decreased by 4.3 mm to 64.6 ± 9.3 mm. The average follow-up period was 214 days. In 18 patients, the sac reduced in size from 0.2 to 47.62 mm/100 days; in 3 patients, there was continued AAA expansion (0.6 to 4.31 mm/100 days); there was no change in the sac size in 4 patients after the procedure. Once treated, the recurrence rate of T2L was low (Fig). The patients with sac growth tended to be associated with higher body mass index and baseline estimated glomerular filtration rate levels (P = .09). This initial multicenter evaluation of the effectiveness of fusion image-guided translumbar obliteration of T2L demonstrated that the technique was effective at all three study centers and showed excellent midterm efficacy to reduce AAA sac size. This may become a more effective and efficient method of treating T2L after endovascular aortic repair going forward.

Manutenção da anestesia inalatória com a máscara facial Janus para substituição de válvula aórtica transcateter: uma série de casos

Background and objectivesAortic stenosis is the most common type of heart valve disease. Percutaneous aortic valve replacement has become the alternative for patients considered at high risk for surgery. Controlled mechanical ventilation with tracheal intubation has been the choice for this type of procedure, however the use of noninvasive ventilation in cardiac patients has shown to be beneficial. Janus is a novel full‐face mask that allows application of noninvasive ventilation support during anesthesia. Our main objective was to evaluate the feasibility of transcatheter aortic valve replacement with prolonged transesophageal echocardiographic monitoring under deep inhalational sedation delivered through a new mask for noninvasive ventilation. MethodsA case series observational study that included five patients with critical aortic stenosis that underwent inhalational anesthesia with sevoflurane for transcatheter aortic valve replacement in a hybrid room of a teaching hospital. Standard monitors and bispectral index were used, followed by inhalational induction and placement of the Janus mask. Anesthesia was maintained with sevoflurane. Patients were transferred to intensive care unit after the procedure. Complications related to the mask use, transesofageal echocardiography accessibility and respiratory implications to the patients were recorded. ResultsAll procedures were uneventful and no major complications were observed intraoperatively. One patient presented CO2 retention (50mmHg) and sevoflurane leak around the central opening of the mask, both without clinical significance. ConclusionsThe use of inhalational anesthesia with the facial mask Janus is a safe and efficient alternative to general anesthesia with tracheal intubation for transcatheter aortic valve replacement and can easily accommodate the use of transesophageal echocardiography intraoperatively.

Radiation Dose Reduction During EVAR: Results from a Prospective Multicentre Study (The REVAR Study)

To evaluate radiation exposure in standard endovascular aneurysm repair (EVAR) using intra-operative guidance with pre-operative computed tomographic angiography (CTA) fusion and strict ALARA guidelines in a modern hybrid room. Between February and November 2016, consecutive patients with AAA undergoing EVAR with a bifurcated device in a hybrid room under fusion imaging guidance were prospectively enrolled in six aortic centres from the United States (n=1), Europe (n=4), and Japan (n=1). Demographic data including body mass index (BMI), indirect dose area product (DAP), cumulative air kerma (CAK), variables influencing dose delivery, and contrast media volume were collected. 85 patients (90.4% males) were included. The median age was 75 (IQR 69-81), with a median BMI of 27.4 (IQR 24.7-30.6). Median DAP and CAK were 14.7 (IQR 10.0-27.7) Gy·cm2 and 107 (IQR 68.0-189.0) mGy, respectively. The median contrast volume was 47mL (IQR 35-70) (equivalent to 14.1g of iodine [IQR 10.5-21.0]). Median DAP per centre was 28.1 (n=16, IQR 12.6-47.1), 15.9 (n=11, IQR 11.9-22.5), 14.2 (n=12, IQR 10.9-25.7), 20.2 (n=18, IQR 7.0-39.5), 10.3 (n=27, IQR 8.2-14.7) and 26.5 (n=1) Gy·cm2. In multivariable analysis, collimation was the only factor that was significantly associated with DAP reduction, (coefficient=-0.014 per percentage of collimation, 95% CI -0.019 to -0.008, p<.001). With adherence to the ALARA principle and routine application of fusion imaging guidance for EVAR, low radiation exposure compared with the published literature can be achieved in a real world setting.

Our experiences on endovascular and hybrid treatment of peripheral arterial diseases.

This study aims to present our experiences on endovascular and hybrid treatment of peripheral arterial diseases. Between March 2008 and April 2016, 86 patients who underwent endovascular treatment and 17 patients who underwent hybrid treatment for peripheral arterial disease in our clinic were retrospectively analyzed. The treatment approaches, success of treatments, complications and outcomes of these patients were studied. No mortality was seen during the procedures. Following the procedure, the patients were hospitalized in the intensive care unit under standard heparin treatment for six hours at least. Anticoagulation was maintained with low-molecular-weighted heparin for three days, followed by dual oral antiaggregant (acetylsalicylic acid 100 mg + clopidogrel 75 mg). Repeated Doppler ultrasonography revealed no in-stent thrombosis or restenosis at the site of ballooning during hospitalization. None of the patients with normal renal functions preoperatively experienced severe renal failure. Although nearly all femorodistal interventions were performed in the antegrade way, none of the patients had bleeding complications at the site of intervention. All patients were discharged within 1 to 16 days. Endovascular and hybrid modalities are safe and comfortable in the treatment of peripheral arterial diseases for vascular surgeons having a hybrid room.

Pattern and degree of radiation exposure during endovascular surgery performed using a mobile C-arm or in a hybrid room.

PurposeA prospective study was conducted to compare radiation exposure to different parts of an endovascular surgeon's body when using a mobile C-arm with that in a hybrid room.MethodsExposure during individual procedures performed on 39 patients with a mobile C-arm and 42 patients in a hybrid room, from July 2016 to December 2016, was evaluated.ResultsThe procedures performed, fluoroscopy time, and dose-area product were not significantly different between groups. The dose-area product per second in the hybrid room group appeared greater than in the C-arm group (4.5 µGym2/sec vs. 3.1 µGym2/sec). In the C-arm group, the peak skin dose on the right neck (1.77 mSv) and shoulder (1.48 mSv) appeared higher than those on their left side (0.32 mSv, 0.53 mSv, respectively) and the counterparts of the hybrid room group (0.88 mSv, 0.20 mSv, respectively).ConclusionThe peak skin dose in the hybrid room appeared highest for the lower part of the protective apron. The dose-area product per second seemed to be greater in the hybrid room than when using the C-arm. Thus, attention should be focused on protecting the surgeon's upper body when using the C-arm and the lower body when using the hybrid room.

Inhalational anesthesia maintenance with the Janus facial mask for transcatheter aortic-valve replacement: a case series

Background and objectivesAortic stenosis is the most common type of heart valve disease. Percutaneous aortic valve replacement has become the alternative for patients considered at high risk for surgery. Controlled mechanical ventilation with tracheal intubation has been the choice for this type of procedure, however the use of noninvasive ventilation in cardiac patients has shown to be beneficial. Janus is a novel full-face mask that allows application of noninvasive ventilation support during anesthesia. Our main objective was to evaluate the feasibility of transcatheter aortic valve replacement with prolonged transesophageal echocardiographic monitoring under deep inhalational sedation delivered through a new mask for noninvasive ventilation. MethodsA case series observational study that included five patients with critical aortic stenosis that underwent inhalational anesthesia with sevoflurane for transcatheter aortic valve replacement in a hybrid room of a teaching hospital. Standard monitors and bispectral index were used, followed by inhalational induction and placement of the Janus mask. Anesthesia was maintained with sevoflurane. Patients were transferred to intensive care unit after the procedure. Complications related to the mask use, transesofageal echocardiography accessibility and respiratory implications to the patients were recorded. ResultsAll procedures were uneventful and no major complications were observed intraoperatively. One patient presented CO2 retention (50mmHg) and sevoflurane leak around the central opening of the mask, both without clinical significance. ConclusionsThe use of inhalational anesthesia with the facial mask Janus is a safe and efficient alternative to general anesthesia with tracheal intubation for transcatheter aortic valve replacement and can easily accommodate the use of transesophageal echocardiography intraoperatively.

Electrical double layer modulation of hybrid room temperature ionic liquid/aqueous buffer interface for enhanced sweat based biosensing

We have investigated the role of kosmotropic anionic moieties and chaotropic cationic moieties of room temperature hydrophilic ionic liquids in enhancing the biosensing performance of affinity based immunochemical biosensors in human sweat. Two ionic liquids, 1-butyl-3-methylimidazolium tetrafluoroborate (BMIM[BF4]) and choline dihydrogen phosphate (Choline[DHP]) were investigated in this study with Choline[DHP] being more kosmotropic in nature having a more protein stabilizing effect based on the hofmeister series. Non-faradaic interfacial charge transfer has been employed as the mechanism for evaluating the formation and the biosensing of capture probe antibodies in room temperature ionic liquids (RTILs)/aqueous human sweat interface. The charge of the ionic moieties were utilized to form compact electrical double layers around the antibodies for enhancing the stability of the antibody capture probes, which was evaluated through zeta potential measurements. The zeta potential measurements indicated stability of antibodies due to electrostatic repulsion of the RTIL charged moieties encompassing the antibodies, thus preventing any aggregation. Here, we report for the first time of non-faradaic electrochemical impedance spectroscopy equivalent circuit model analysis for analyzing and interpreting affinity based biosensing at hybrid electrode/ionic liquid-aqueous sweat buffer interface guided by the choice of the ionic liquid. Interleukin-6 (IL-6) and cortisol two commonly occurring biomarkers in human sweat were evaluated using this method. The limit of detection (LOD) obtained using both ionic liquids for IL-6 was 0.2 pg mL−1 with cross-reactivity studies indicating better performance of IL-6 detection using Choline[DHP] and no response to cross-reactive molecule. The LOD of 0.1 ng/mL was achieved for cortisol and the cross-reactivity studies indicated that cortisol antibody in BMIM[BF4] did not show any signal response to cross-reactive molecules. Furthermore, improved sensitivity and LOD was achieved using ionic liquids as compared to capture probes in aqueous buffer.

Tailored intraoperative localization of non-palpable pulmonary lesions for thoracoscopic wedge resection using hybrid room technology.

VATS wedge resection can require conversion to thoracotomy when pulmonary lesions cannot be identified. Hybrid operating rooms (HORs) provide real-time image acquisition capabilities allowing the intraoperative placement of markers to facilitate the removal of non-palpable nodules during VATS. To present our workflow based on the alternative use of two different markers according to the location of the lung lesion and report our initial results. All consecutive patients with non-palpable lesions requiring VATS wedge resection underwent localization of the targets in HOR. Lesions were considered non-palpable if they were small (<1cm), deep (>1cm from surface), subsolid, or located within a dystrophic area. Anesthetized patients were placed in lateral decubitus. Cone-beam CT (CBCT) was performed, and the needle trajectory was planned using Syngo iGuide Needle Guidance. Metal hook-wire or coil was placed, according to our workflow, close to the lesion and their position was verified by CBCT or fluoroscopy. Eleven VATS wedge resections were performed in 10 patients with 12 non-palpable lesions. The localization was performed with seven hook-wires and four coils in 30minutes (range 17-56minutes). The median estimated total effective dose was 11.6mSv (range 1.9-24.7mSv). Eleven lesions were removed by VATS, and one deep nodule required a thoracotomy. No complications were observed. Our experience confirms that HOR is suitable for simultaneous localization and VATS resection of 'difficult' pulmonary lesions. A versatile approach, using different devices, seems advisable for the removal of targets in every clinical scenario, reducing the VATS conversion rate.

Laparoscopic partial nephrectomy following tumor embolization in a hybrid room. Feasibility and clinical outcomes

PurposeIn order to limit ischemia and operative bleeding during and after partial nephrectomy we developed a clampless laparoscopic technique, in a hybrid operating room, immediately after super-selective arterial embolization of the renal tumor. We evaluated feasibility and morbidity of this new approach of zero ischemia in partial nephrectomy. MethodsWe included prospectively 50 consecutive patients treated in a hybrid operating room by this new technique for a localized renal tumor in a university hospital between May 2015 and January 2017. We evaluated perioperative data, postoperative complications, surgical margin and modification of renal function one month after surgery. Renal tumor complexity was evaluated by the R.E.N.A.L. score. ResultsWe included 30 (60%) men and 20 (40%) women with a median age of 61 years (32–84) and a median BMI of 26.85 kg/m2 (20.1–46.4). Tumors were at low, median and high complexity in respectively 11 (22%), 32 (64%) and 7 (14%) cases. Median endovascular and surgical procedures durations were 43 min (16–120) and 80 min (32–150). Median blood loss was 100 mL (10–850). Two Clavien II complications occurred. Median length of hospital stay was 3 days (2–7). Renal function was not modified one month after partial nephrectomy. Median tumor size was 3 cm (1.2–8). Forty tumors (80%) were malignant and surgical margins were positive in one (2%). ConclusionsClampless laparoscopic partial nephrectomy in a hybrid operating room without pedicular dissection after previous tumoral embolization is a technically safe and carcinologically efficient mini-invasive alternative for the management of localized renal tumors.

IP007. Simplified Translumbar Treatment of a Type II Endoleak Using CT Fusion in Hybrid Room

A 74-year-old man underwent endovascular aneurysm repair (EVAR) of a 5.0-cm infrarenal abdominal aortic aneurysm (AAA) with a stent graft. Endoleaks were not detected at the time of the completion angiogram. Follow-up aortic duplex study obtained 1 month later showed the presence of a small type II endoleak arising from the inferior mesenteric artery (IMA). The endoleak persisted and increased in size, with a subsequent sac diameter increase 3 years after EVAR. A follow-up computed tomography angiogram (CTA) showed the presence of type II endoleak, with retrograde filling by the IMA and connection to a complex network of lumbar vessels. The AAA sac increased in size to 5.8 cm. Decision was made to proceed with treatment to obliterate this endoleak. We describe a novel approach in treating a persistent type II endoleak related to the IMA and the lumbar outflow vessels using a simplified translumbar approach. Using TrackVision software, we were able to delineate the track to the level of the endoleak. The software program allowed us to access the endoleak through a translumbar approach. A three-dimensional cone-beam CT scan without contrast injection was used to identify the location of the endograft to match the exact position of the endoleak noted on the previous CTA in the superimposed prone position. After the entry and target trajectories were identified using both of the fused data sets, the model and planned trajectories were then exported into the TrackVision software, creating a virtual needle track. A 20-cm long, 18-gauge Chiba needle was used to access the endoleak cavity. Using progress and bull’s eye views, we were able to track the needle into the endoleak. The endoleak was then visualized using contrast showing feeding of the endoleak through the IMA. This entire region was then coil embolized with a total of four 4-mm × 3-mm Tornado Embolization Coils followed by one 5-mm × 10-cm and two 10-mm × 15-cm Nester Embolization Coils. After coil embolization the IMA was not visualized. The patient was seen in follow-up 1 month following the procedure with complete obliteration of the endoleak and decrease in sac size to 5.3 cm. This simplified approach at treating complex endoleaks has allowed the procedure to be performed with minimal fluoroscopy and digital subtraction angiography imaging. In addition, the length of the procedure has become significantly shortened with the use of the virtual needle track.Fig 2View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Clipping of ruptured intracranial aneurysms in a hybrid room environment-a case-control study.

Hybrid room treatment (HRT) provides the surgeon immediate intraoperative angiography control of aneurysm occlusion and vessel patency. Since it is relatively resource demanding, in clinical routine HRT is reserved for elective cases. However, since its introduction in our department in 2008, several random cases of ruptured intracranial aneurysms (IAs) have been treated in the HR. This study aims to compare the clinical and radiological outcomes of these cases with cases treated conventionally using a matched pair analysis. Twenty (20%) consecutive patients with ruptured IA treated by microsurgical clipping in the HR between 2009 and 2015 were retrospectively matched with "conventionally" (C) treated patients (overall n=101). Clinical and radiological outcome variables were assessed and compared. Despite a trend in favor of the HR group, no significant difference between both matched groups (HR vs. C) could be demonstrated regarding the functional outcome (upper/lower good recovery 16/20 vs. 17/20, p>0.05), frequency of clipping-related vascular insults on CT scans (0/20 vs. 3/20, p>0.05), aneurysm remnant rate on postoperative angiography (1/20 vs. 4/20, p>0.05) and retreatment rate (0/20 vs. 1/20, p>0.05). When cumulating all outcome events by a scoring system, however, the HR cohort showed a significantly lower occurrence of events (p<0.05). In three cases co-treatment by an endovascular approach was performed in the HR cohort. In this relatively small cohort, a matched pair analysis revealed a discrete but not significant tendency toward a lower frequency of aneurysm remnants and clipping-related vascular insults in the HR cohort. However, HR cohort patients benefited from direct endovascular co-treatment in selected cases.

Local anaesthesia with analgosedation in patients qualified for transcatheter aortic valve implantation (TAVI): first institute's results and experiments.

The authors present their own experience of the treatment of patients qualified for transcatheter aortic valve implantation (TAVI) carried out in a modern hybrid operating room. The objective of the present study was to demonstrate the initial results of conducting anaesthesia in high-risk patients qualified for the TAVI procedure (transcatheter aortic valve implantation). In addition, the authors' aim was also to point out to the special challenges of an anaesthesiologist conducting local anaesthesia in such a type of procedures and to evaluate the safety and efficacy of the TAVI procedure conducted under remifentanil analgosedation. A retrospective analysis included patients treated during the period from September 2015, when local anaesthesia for the transcatheter aortic valve implantation was used for the first time at our centre, up to February 2016. The studied population consisted of 11 patients treated for severe aortic valve stenosis. The mean age of patients was 80 ± 7 years. Three patients were men (27%) and eight were women (73%). The study included all subsequent patients (n = 11), treated in our centre, for whom it was decided to perform TAVI under local anaesthesia. The total hospital mortality rate was 0%. All procedures were performed in a hybrid operating room. Despite the complications observed in the described group, the hospital mortality rate during TAVI was 0%. All patients, after 12 ± 5 days of treatment, left the hospital in a good neurological condition, which was assessed based on the CPC-1 (Cerebra Performance Categories Scale) and GCS-15 (Glasgow Coma Scale) scales. With an ejection fraction of the left ventricle of 53 ± 11%, the transcatheter aortic valve was successfully implanted. Percutaneous aortic valve implantation can be successfully conducted under remifentanil analgosedation. TAVI procedures should be performed in the conditions of a modern, well-equipped hybrid room. The aim of the anaesthesiologist should consist of conducting the least invasive anaesthesia/analgesia, bearing in mind the safety and comfort of the patient.

What should we expect from the hybrid room?

The concept of hybrid room was defined as an optimized surgical theater, offering the best compromise between asepsis criteria from standard surgical rooms and high quality imaging equipment from fixed radiological suites. This review aimed at summarizing what vascular surgeons should expect from hybrid rooms in daily practice and in the near future.

Interventional Therapy for Pulmonary Embolism.

Patients with pulmonary embolism (PE) present with highly variable clinical symptoms and often have accompanying comorbidities. Timely diagnosis and treatment are critical to help prevent recurrence and increased morbidity/mortality. While open surgical thrombectomy was once reserved only for those with massive PE and hemodynamic compromise, it has been reevaluated with a focus on careful patient selection and early intervention. Lately, there has been increased interest in catheter-based interventions and in combining these with an open surgical component to decrease the magnitude of the intervention-for example, direct placement of large-bore thrombectomy devices directly into the right ventricle via sternotomy or subxiphoid approaches. In addition, improved diagnostic capabilities have allowed for expedited diagnosis and treatment of patients with life-threatening PE. At our institution, a hybrid room allows patients suspected of having a massive or submassive PE to undergo on-table contrast-enhanced cone-beam computed tomography scan, thus creating a high-resolution 3-dimensional image of the arterial system that can provide immediate guidance for therapeutic intervention. This review highlights the array of therapeutic options currently used in our armamentarium at the Houston Methodist DeBakey Heart & Vascular Center and describes our development of a pulmonary angioplasty procedure that we believe will greatly facilitate selective thrombus removal in the acute PE setting.

Implantação e funcionamento de sala híbrida em hospital privado de São Paulo

Objetivo: Relatar a experiência da implantação de sala operatória híbrida e identificar sua demanda de funcionamento em hospital privado de São Paulo. Método: Estudo retrospectivo, com relato de experiência. Para coleta foram utilizadas informações do banco de dados do centro cirúrgico, registradas em instrumento (caracterização da amostra, informações sobre a cirurgia e utilização da sala híbrida). Resultados: 166 pacientes foram atendidos em 15 meses; a maioria do sexo masculino (109; 65,7%), faixa etária de 71 a 80 anos (42; 25,3%), com diagnóstico de estenose aórtica (25,9%), nas especialidades cardiologia (70,7%) e vascular (16,5%). Os recursos mais utilizados foram: ArtisZeego®, arco C, circulação extracorpórea, equipamentos audiovisuais, softwares, ultrassonografia, ecocardiograma e Robô Da Vinci®. Conclusão: A implantação da sala híbrida é um conceito inovador, com integração de equipes e utilização de recursos de nova geração. A equipe deve estar em constante aprendizado, pois dificuldades na formação dos profissionais e alto custo têm limitado esses procedimentos a poucos centros do mundo.

What Do They Do In That Hybrid Room?

What Do They Do In That Hybrid Room?