Munroe Regional Medical Center introduces the newest hybrid operating room and cath lab model with the latest cutting edge technology in the industry, placing two disciplines together to perform less invasive treatments, right here in Ocala/Marion County.

Story: John Sotomayor

Heart rates are climbing at Munroe Regional Medical Center’s award-winning Munroe Heart program with the sense of excitement over their next evolutionary step to provide the best cardiac care for the community. They will soon propel Ocala/Marion County into the esteemed medical company of the University of Miami Hospital and the Children’s Heart Center at Phoenix Children’s Hospital through the introduction of the latest version of the hybrid lab, combining a catheterization (cath) lab with an operating room. University of Miami Hospital constructed theirs in December 2011. Construction at MRMC is slated to begin mid-February and should be fully operational by mid-May.

“The heart and cath program has been around [in Marion County] for 23 years,” said Pam Michell, Chief Nursing Officer of Munroe Regional. When it began, the heart and cath program was the first to have open-heart and catheterization capabilities offered to the community. The purpose was to offer the community the best practices and standards of cardiac care. Two years ago for instance, Munroe Regional added a state-of-the-art electrophysiology program. The hybrid lab will take the standard of care to the next level.

Munroe Regional has been talking about the hybrid lab for about a year. The team concept – the interventionalist working together with the surgeons – has always been established at Munroe Regional in the 23 years of the heart program, “so it was a natural progression for us,” said Carol Floyd, Director of Cardiovascular Services.

The actuality came to fruition in October 2011, when hospital administrators and medical teams looked at everything and determined that the time was right. They needed to know that they had the right equipment and the room was adequate. It was quite an undertaking. There is a new percutaneous aortic valve procedure that was just approved in late November that kicked the team into high gear.

Intravascular suites, or hybrid labs, are becoming much more common, sprinkled throughout the state, the southeast and the country. The technology and concept for the hybrid lab became available in 2005. There are several in Florida according to Dr. Gregory von Mering, Interventional Cardiologist of Munroe Heart, such as the one at Shands, the University of Florida. The equipment that will be installed at Munroe Regional is simply newer.

How it Works

The idea behind a hybrid cardiovascular operating room has grown out of the evolution of vascular procedures from those that were strictly surgical or strictly catheter based to those that actually combine techniques from both fields. When a medical team combines techniques from both fields, they optimally require an environment that would allow the team to conduct those procedures.

Placing both into the same space serves two functions: diagnostic and surgical.

Basically, it takes the x-ray based imaging equipment from a cauterization laboratory, also known as an angiographic suite, and it puts that imaging equipment in an operating room (OR) that is built and designed for open surgical procedures. The individuals that will work in that environment can perform an open operative procedure with the comforts and expectations of a standard OR while at the same time, be able to image and guide their procedure using the most advanced angiographic techniques that would normally be used in a catheterization laboratory.

“It gives you the best of both worlds,” said Dr. von Mering adding that it allows the medical team to do complex procedures that can combine the skill sets of both the surgical physicians and the angiographic physicians – both interventional cardiologists and interventional radiologists.

Cutting Edge

The latest system being installed in hospitals in 2011-12 is called the Flex Move. In a standard cath lab, the C-arm on the surgical table resembles a very large letter C on a track from the ceiling. It will go around on the right side of the patient on the shoulders and can go around on the left side of the patient on the shoulders. It has a small arch that it can travel. In a surgical setting, the doctor may need to operate if something goes wrong. The doctor may need to convert to open surgery, but that C-arm is in the way because the anesthesiologist has to be at the head of the bed, and the sterile trays have to be over to the side so having a regular room is not conducive to converting to surgery.

“It allows the team to do things that normally have to be done in two separate environments to be done in one place,” said Dr. von Mering.

The Philips based angiographic equipment supplied to Munroe Regional is certainly cutting edge in terms of its digital technology and provides highly advanced imaging in a wide capacity as the entire abdominal aorta to a small focal point as a coronary artery. The advanced system allows the team to image the area from multiple angles at the same time not compromising surgical access to the surgical site.

The Philips Hybrid OR Solutions include: Allura Xper FD20: a flexible x-ray system with a large 20-inch field of view for minimally invasive cardiac surgery; an Allura 3D-CA which creates 3D visualization based on rotational angiography of the coronary arteries; a CT TrueView which creates 3D visualization based on a CT-dataset of the coronary arteries; the StentBoost, which visualizes stents in the coronary arteries in relation to the vessel lumen in real time; and the iE33 with Live 3D TEE and QLAB, which can assist interventional procedures and provide comprehensive quantitative information to support critical decisions.

The equipment can be moved into the field or removed from the field easily and can be seamlessly integrated with the surgical table so that whatever position the surgeon optimally wants can be achieved at the same time whatever imaging angle is required by the angiographer.

“It doesn’t sound like much, but allowing the surgeon and the anesthesiologist access to the patient, that is a big deal,” said Floyd.

Benefits of a Hybrid Lab

The primary benefit of having the cath lab and OR together in one setting is providing the ability to accommodate more advanced procedures now being performed such as aneurism repair via the groin, the new aortic valve replacement via the groin. The OR is the best setting for that because of the environment and the outside chance that something would happen.

In the past, medical treatment may have only had a surgical approach for an aortic aneurism, for example. Now, with the development of technology that allows medical teams to treat aortic aneurisms with stet grafts, even sometimes with holes in the sides to accommodate blood vessels that come off the aorta. The medical teams require that ability and environment to surgically open an artery to advance that device but also need the highly precise imaging technology of the catheterization laboratory to position the graft then locate the blood vessels coming off the aorta so they are not compromised.

Munroe Regional has selected to build it as a cath lab within an OR, spacious and sterile with state-of-the-art technology so the medical team can do these procedures. The invasive cardiologist can have their C-arm imaging capability that is much better than a portable and the cardiac surgeon and vascular surgeons can also have this imaging to do these more complex procedures.

Using a portable C-arm is not as good because the images are weak. They are not bad, but they are not as good as they need to be, containing fuzzy, grainy snow. The imaging that is used in the cath labs is very crisp and clear, almost like high definition television compared to the old analog television.

The surgeons and the invasive cardiologists have to work closely together doing procedures like an abdominal aortic aneurism, known as an endovascular AAA, via a catheter rather than making an incision and opening the patient. To do those procedures successfully, the medical team really needs the good imaging quality. Rather than to take a patient from the cath lab to have images done then to the OR to have the procedure, this allows the medical team to do it all at one time.

The recovery time is 24 to 48 hours versus 6 to 8 weeks for an open-heart surgery. At times, it is not possible to have just the catheterization, the patient may need more than that because of more advanced disease or the blockage is located somewhere that the catheter cannot get to. When a medical team needs to perform an open-heart surgery, instead of opening the chest and opening the heart and replacing the valve that way, they make a small incision in the groin and the catheter is taken up into the heart and the valve is implanted that way.

The medical teams at Munroe Regional are anticipating the participation of cardiothoracic surgeons, vascular surgeons, interventional radiologists, and interventional cardiologists all in a multi-disciplinary program to take care of a variety of illnesses ranging from perfoarterial disease, aneurismal disease, hybrid-coronary artery procedures, to percutaneous treatment of aortic valvular disease.

Munroe Regional wants to offer a heart program to the community that has all the components that meet the needs of the community. While other hospitals in Florida have hybrid labs, the one being added to Munroe Regional and thus, Marion County has “the latest and greatest technology as far as hybrids are concerned,” said Michell. The introduction of the hybrid cath lad/OR speaks very highly of the already very successful heart program.