Tour of the New Hybrid, Robotic Operating Room at Methodist: Interview with Dr. Miguel Valderrábano

The Methodist DeBakey Heart & Vascular Center recently opened an innovative hybrid, robotic operating suite, which integrates advanced robotics, imaging and navigation with surgery to offer patients the least invasive and safest surgical and interventional treatments for cardiovascular disease. In this interview we speak with Dr. Valderrábano, chief of the division of cardiac electrophysiology at Methodist, about the types of procedures that will take place in the new hybrid suite. What prompted the creation of the new hybrid, robotic operating room? The natural evolution of cardiovascular procedures over the past few years has blurred the boundary between surgical and interventional EP procedures. We have been more aggressive in exploring new strategies and going beyond our usual route for EP procedures, including with the epicardial approach. When doing epicardial ablations, we typically get pericardial access with a subxyphoid puncture, but occasionally we see patients that have extensive scar tissue due to previous thoracotomies, so we need a surgeon to open up our access to the epicardium with a pericardial window. Therefore, the boundary between the surgical procedure and the cardiology procedure is getting more and more blurred. That’s just one example. Other examples are hybrid approaches for atrial fibrillation (AF) ablation, where in the same procedure and setting, the patient may have part of a procedure done by a surgeon and another component performed by a cardiac electrophysiologist. This phenomenon has occurred already in many other areas of cardiovascular procedures, including coronary bypass surgery in which a surgeon can do endoscopic bypass using a mammary artery, and in the same setting, the patient may get angioplasty or stenting in other vessels. So in one go, the patient may get a hybrid revascularization. Additionally, there are hybrid vascular surgery procedures in which the vascular surgeons do part of their procedures, for example, they need to operate on the aortic root or in a descending aorta, and at the same time they may deploy a stent in one component and then do an open procedure in another component. Finally there are newer procedures being developed such as percutaneous heart valves, that may require input from both a surgeon and a cardiologist. We are developing a program of structural heart interventions at Methodist. This will include percutaneous valve deployments and other structural heart assist interventions that will bridge electrophysiology, interventional cardiology, and cardiac surgery. The hybrid suite is uniquely designed for that, so percutaneous aortic valve deployments, appendage occlusion devices or other structural interventions that may require a higher level of invasiveness are ideal cases for this type of room. It has been a phenomenon that has occurred through several pathways, not only in electrophysiology, that has led to the need for equipment and setups that can accommodate both surgical procedures (with the anesthesia and the sterility required) as well as endovascular procedures with all the equipment required for electrophysiology recording systems, three-dimensional mapping systems, robotics, etc. How long did it take for the room to be completed? Construction started in August 2009 and was completed in February 2010. The interior construction started in March 2010 and was completed on July 19, 2010. It opened for cases on July 22, 2010. The room is large for cath lab standards, and it’s still open, meaning there is still equipment yet to be added. We plan on adding the robotic systems in there, as well as including additional mapping systems. Right now it is fully functional, but it is not yet operational as an electrophysiology lab. What is the size of the new hybrid suite? There is 950 square feet of usable space in the suite, plus a control room. Tell us about some of the equipment that will be included in the room. The room is more of a combination of existing equipment, not so much ‘new’ equipment. The room will include equipment capable of performing CT angiograms with reconstructions with a flexible robotic C-arm. The room also will contain the robotic catheter guidance system by Hansen Medical. The room is going to be utilized for robotic procedures, not only for EP, but for vascular surgical procedures as well. The room features a large monitor that can display at once all the sources of information that we have, because as you know in an EP lab it can get very cluttered having to watch 4 different monitors for x-ray information, the intracardiac echo, EP recordings, 3D mapping, etc. What other unique design elements were used in this space? In terms of layout, other than the fact that it is big and spacious, it will be able to accommodate a whole host of different procedures and technologies all in one. How many procedures have been performed thus far? More than 50 cases have been performed in the room since its opening. Where will the new suite be located in relation to the procedure rooms for the EP and cath labs? Currently we have 8 of the 10 cath labs on the 10th floor, including 3 of the EP labs. We also have 2 EP labs on the fourth floor; the hybrid suite will be located on the third floor, one floor below. Who will this room be managed by? Tell us about the collaboration between the departments. Since the suite will be located next to the surgical suites, it will be managed by the surgical administrative staff, who normally coordinate very closely with the cath lab. For years anesthesiology has been part of the scheduling process for the cath and EP lab as well as the operating rooms, especially since we started the program for atrial fibrillation (AF) at Methodist — it was my firm belief that anesthesia had to be involved in those cases. What EP procedures will be performed here? When will the first case take place? The ideal procedure as of now is the hybrid atrial fibrillation (AF) ablation procedure. This is using the nContact device, whereby a surgeon makes an incision in the abdomen and inserts an access tube into the pericardial space, and through that incision delivers part of the lesion set of a maze procedure, aiming to deliver what can be done through an inferior approach from the diaphragm. In the same setting, the electrophysiologist goes in endovascularly and completes the lesion set through a conventional transseptal puncture and access to the left atrium. That kind of procedure, the so-called convergence procedure, requires a combination of different expertises and support equipment and staff, so you have to have a surgical table and surgical staff support in the OR, and at the same time you need to have the EP equipment in there. In most cases this procedure has been performed in the EP lab, much to the surgeon’s discomfort, because EP labs are not often suited to have a surgical tray or the instruments the surgeon may require (endoscopic tools for the surgeon to get from the diaphragm into the heart, and so forth). So that is one procedure that I think has the most immediate application. Going beyond that, I could mention there are patients that require ablation that require epicardial access in whom accessing the epicardium with a conventional subxyphoid puncture might not be possible because of previous surgery; therefore, we may need a surgeon to open a small incision or pericardial window so we can access the pericardium. That is another type of procedure that would require a hybrid room. There are also patients with structural heart disease that may require cardiac surgery, for example, mitral valve surgery, but may also have ventricular tachycardia and may be subjected to mapping by a surgeon that requires EP expertise and equipment to be performed at the same time the other component of the cardiac surgery is performed. The ability to have the access that a surgeon can get you by opening the chest, and combining this with EP equipment and mapping, is a whole new frontier. How will the use of a hybrid suite affect procedure time? It won’t so much shorten procedures but will combine our procedures. For example, regarding hybrid approaches to atrial fibrillation, currently there are two separate setups — first the patient has the surgical maze procedure, and then if there is any adding or touching up to be performed, that would be performed by the electrophysiologist in a second procedure. By having a room with the capability to do surgery as well as EP studies and ablation, both procedures can be combined into one, so patients can get one hospitalization, one anesthesia, and when they wake up they have the best of both worlds — best of what surgery and EP can offer. When doing AF ablation, most surgeons will create a maze set of lesions, but they have very minimal or crude mapping abilities for testing how solid the lesions are or the conduction block they have achieved — this is substandard for an electrophysiologist. But if in the same setting you have the ability to introduce in the patient all our equipment — our mapping system and EP recording system — we can then improve the quality of what the surgeon does and even if it requires it be touched up endovascularly, at least we could deliver additional lesions to optimize the procedure. So I don’t think this kind of setting will shorten existing procedures — it is more geared to combine two procedures into one as well as to combine different expertises and equipment abilities into one single procedure. For more information, please visit: www.methodisthealth.com/