am particularly pleased with is air conditioning to the south. Having moved here from Boston recently, I cannotimagine liv...
deployed a stent, they would not imagine ever deploying a stent without a completion angiogram to show thateverything was ...
have a cell phone here somewhere, but people canít live without their cell phone. I mean, what weíre doing isweíre just ra...
operating room is instrument rated. You know exactly how far that plane is from the water. You know exactly theair speed a...
operating room into a cath lab, but my view is that we need to make it user friendly for our friends ininterventional card...
What about mid calf and endoscopic mammary harvest, along with stents to non-LAD vessels? Dr. Zhao, do youthink thatís a r...
DAVID ZHAO, MD: Thatís right. Look at the paper you wrote in JACC and that group of patients, very sickpatients, the predi...
JOHN BYRNE, MD: As surgery becomes more minimally invasive and as interventional cardiology becomes moreaggressive, they b...
November and thatís what weíve found. That was for the first 25 or 30 patients. Now we have nearly 100 patientsin our seri...
surgery. In my view, we will not be able to imagine a world without imaging in the cardiac surgical operatingroom in the f...
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  1. 1. HYBRID OR OFFERS ‘SIGHTED’ CARDIAC SURGERY VANDERBILT UNIVERSITY MEDICAL CENTER NASHVILLE, TENNESSEE Broadcast September 29, 200500:00:16.000NARRATOR: Welcome to Vanderbilt University Medical Center in Nashville, Tennessee. You are about to see anew, innovative way to perform heart surgery that will have an impact on the cardiovascular world. This newoperating facility, called a hybrid OR, combines the cath lab with an operating room, allowing surgeons toperform sighted cardiac surgery.00:00:39.000JOHN BYRNE, MD: I called it sighted cardiac surgery, as opposed to unsighted or blind cardiac surgery, becausein virtually every reconstructive procedure in life and certainly every reconstructive procedure in medicine andsurgery is accompanied by before and after pictures, with the exception, the very unique exception, of coronarybypass surgery.01:01:05.000NARRATOR: Vanderbilt University Medical Center will demonstrate how the combined OR cath lab has changedthat, creating a new standard for the treatment of cardiovascular disease. At any time throughout the next hour,email your questions to the physicians by clicking the MDirectAccess button on the screen.00:01:17.000JOHN BYRNE, MD: Hi. My name is Dr. John Byrne. Iím the Chairman of Cardiac Surgery here at VanderbiltUniversity Medical Center in Nashville, TN. Iím with Dr. David Zhao, the Chief of the Cath Lab here at Vanderbiltand weíre going to today share with you our experience in what we call the sighted operating room or a hybridoperating room, where we have combined all the tools and technologies of conventional cardiac surgery with allof the tools and technology of interventional cardiology so that we can provide the best possible outcome for ourpatients with complex coronary and valvular heart disease. During this webcast, you will have an opportunity toemail us questions about this new, innovative approach to coronary artery disease and heart surgery, in general,and that can be found on the website, but right now Iíd like to direct your attention to a PowerPoint presentationwhich we have prepared to give you a brief outline of why we think this is important and the general scope of thisidea.00:02:28.000I call this topic sighted or image-guided cardiovascular surgery and hybrid procedures. Heart surgery, in general,is a team sport and we show here the members of our cardiovascular team. On the bottom right there, of course,Dr. David Zhao, who is a fully trained cardiac surgeon and an interventional cardiologist, who together weíredoing this hybrid sighted cardiac surgery project. What this talk will convey is that, in my view, imaging will be toheart surgery what calculators were to slide rules. Not too long ago, in the mid 70s, they actually taught peoplehow to use slide rules, believing that there was a future for slide rules, but within a short period of time,calculators took over that and now slide rules are relegated to history books and antique shops. Imaging will beto heart surgery what the cut and paste keys are to liquid paper. Now we cannot imagine a world without cut andpaste keys. We could not possibly go back to liquid paper and typewriters. Imaging will be to heart surgery whatbottled water is to tap water. Not too long ago, people would not even imagine paying money for water, yettoday we routinely pay money for the various bottled water products and this is a huge industry. Imaging will beto heart surgery what cell phones are to pay phones. Again, not too long ago weíd have to carry dimes andquarters in our pockets to find pay phones, but now itís routine to have a cell phone. In fact, people cannotimagine their lives without a cell phone. Another example would be digital music to vinyl records and one that I
  2. 2. am particularly pleased with is air conditioning to the south. Having moved here from Boston recently, I cannotimagine living in the south without air conditioning and thatís what I view imaging will be to heart surgery.00:04:42.000What these are, of course, are what Mr. Andy Grove, who is the CEO of Intel Corporation, in his book called Onlythe Paranoid Survive, he called it a strategic inflection point, where you can see in that curve on the right wherethe business cycle grows and grows until thereís a point in the business cycle where an event occurs thatpermanently and dramatically changes the nature of the business. I believe imaging will be part of that processfor heart surgery.00:05:21.000Because in virtually every reconstruction surgery in life, let alone in medicine and surgery, they are accompaniedby before and after photos, with the exception of coronary artery bypass surgery, until now at Vanderbilt and acouple of other centers in the United States. Even for things like the Oprah show, a total makeover, theyíreaccompanied by before and after photos. The popular show, the Queer Eye for the Straight Guy, is accompaniedby before and after photos. This show would probably not even be on TV if it werenít for the before and afterphotos because you wouldnít believe that the makeovers are as good as they are without seeing the before andafter photos.00:06:03.000Certainly in plastic surgery, no one would go to a plastic surgeon, typically, without looking at his or her portfolioto see what sort of product theyíre able to deliver. Also in vascular surgery, if someone does a fem distal bypass,the vascular surgeon almost always obtains a completion angiogram to make sure that the foot and the big toehave blood flow, yet we donít do an angiogram to make sure the mammary to the LAD is intact routinely. EvenBotox surgery is accompanied by before and after photos. In this slide it shows that hip surgery, on the left slideit shows that the hip is out, but on the right side of the slide the hip is back in. Of course, these images are takenby orthopedic surgeons at the time of surgery, in the operating room, before they close the wound, to make surethat the hip is reduced to the proper location. No orthopedic surgeon in this country or elsewhere would everimagine leaving the operating room without getting an image of the hip or the shoulder or the knee or any otherbone that is reduced or fixed at the time of surgery; that is, reconstructed at the time of surgery.00:07:25.000Even for gallstone surgery, itís routine to obtain completion cholangiograms to make sure all the gallstones havebeen removed and that the common bile duct does not need to be explored. Even for simple things, like tubesand lines, itís routine to get x-rays to prove that theyíre in the proper place, such as a central line. We wouldnítstart a central line for hyperal until the line is proved to be in the proper place. Thatís really considered below thestandard of care to not get an x-ray.00:08:00.000In mitral valve surgery, on the left hand side of the screen, mitral valve surgery has really been revolutionized byintraoperative transesophageal echo. On the left side of this screen is a video showing a leaking mitral valve andyouíll see above the mitral valve a lot of color here in a moment, showing that the valve is leaking. Based on thisintraoperative echo, we start performing a mitral valve operation, which is depicted in the schematic below,which is a PQ resection and a sliding valvuloplasty and then a ring annuloplasty. After this repair is performed inthe operating room, with the patientís chest still open but still cannulated, we routinely obtain intraoperativetransesophageal echo. This shows that the valve repair is intact. Indeed, intraoperative transesophageal echo haschanged the standard of care for mitral valve repair. I donít think a single heart valve surgeon in America wouldreally consider it reasonable to perform mitral valve repair surgery without the use of intraoperative echo. Soweíre applying the same thing to coronary artery surgery.00:09:17.000In this slide, on the left hand side is a picture of a typical angiogram. This is coronary bypass surgery in middleTennessee and the rest of the United States before 4/4/05. On the left, it shows an angiogram which showstypical 3-vessel coronary artery disease and this patient obviously needs coronary bypass grafting. On the rightside of the screen is a typical after picture which is performed in most operating rooms in the United States. Well,of course, there is no after picture in most operating rooms in the United States. We just believe the anastomosisis fine, we believe the conduit is fine, we believe the flow is fine. Now we can use flow probes and we can useechocardiogram to look at the wall motion and various other techniques, but thereís really no point of care onlineimaging to show that the graft is exactly the way we want it to be, just like if an interventional cardiologist
  3. 3. deployed a stent, they would not imagine ever deploying a stent without a completion angiogram to show thateverything was okay. The reason for this is that the traditional paradigm is that CABG is performed in theoperating room, whereas imaging and percutaneous interventions are performed in a cath lab. At Vanderbilt, likemost other institutions, these are in two separate physical locations. Here, the operating room is on the thirdfloor and the cath lab is on the first floor, so if you wanted to perform imaging, youíd have to go from the thirdfloor down to the first floor and then back up to the third floor. Of course that would be very inefficient andcumbersome. So what weíve done here and what weíd like to talk to you today about is our hybrid lab, where wecombine the camera in the cath lab as well as the regular operating equipment for a regular operating room. Wecall this the integrated cardiovascular care program or hybrid care.00:11:27.000So now what we do, on the left hand side, is a routine preoperative angiogram and on the right hand side is acompletion angiogram that shows that a LIMA-LAD is intact and functioning properly.00:11:50.000Imaging matters because 15% of all vein grafts fail in one year. We know this from old data and this is likely tobe higher in the future because of the advanced nature of coronary disease that comes to surgery. Patients thatcome to surgery are more complex and higher risk than ever and itís probably going to get worse. This is anexample of where we were able to repair a Steel phenomenon. This is a case where a supreme intercostal branchof the left internal mammary artery was still patent and it was attempted to be coiled at another institution, butthis coil recannulized and therefore the patient was referred to us and we localized this intercostal branch with aKelly clamp right there and we ligated it easily using a small incision on the chest wall under local anesthesia.This is a trifurcation lesion. Maybe Dr. Zhao can explain this case. This is a trifurcation lesion that was a hybridprocedure.00:12:59.000DAVID ZHAO, MD: Thatís right. This patient actually comes in with acute coronary syndrome. He has a stenosis.On the angiogram you can see stenosis before the large septal and after the large septal, and also thereísstenosis in the diagonal, which you cannot see with this particular projection. Traditionally, a surgeon will bypassthe LAD and bypass the diagonal and then the large septal is basically unrevascularized and the septal is reallylarge. In the past, we would basically just say thatís too bad, we just have to sacrifice that septal. So what wewere able to do for this particular patient is they bypassed the LAD, bypassed the diagonal, and we were able tostent that into a septal with excellent results, so we completely revascularized this patient.00:14:00.000JOHN BYRNE, MD: On this patient, we performed a mammary to the LAD, shown here. I have an email questionthat Iíll get to in just a second. Then we performed a vein graft to that diagonal with a completion angiogram.These are all intraoperative completion angiograms, which are performed with the chest open, while the patientis cannulated but the chest is open. This slide here shows how Dr. Zhao placed a stent in that large septalperforator.00:14:33.000We just received n email question, asking what are the downsides of the hybrid operating room in terms of renalfunction, cost, and the time to perform the procedure? Maybe, Dr. Zhao, I can direct that question to you. Renalfunction, cost, and the time to perform the angiograms.00:14:54.000DAVID ZHAO, MD: We actually did an analysis for our first few dozen patients and we found out that the renalfunction actually was stable compared to pre-CABG and post-CABG. Thereís no significant difference at all. Ittakes us 15-20 minutes to do the procedure and yes, it is slightly longer than the traditional bypass surgery byabout 15-20 minutes, but think about the fact that you can guarantee the autograft is patent and you canguarantee good outcome for the patients, I think itís absolutely worth that 15-20 minutes prolonged duration forthe surgery. From the cost standpoint and with the collaboration between the surgery and cardiology, we haveminimized down to the minimal equipment we need and we work this in a very efficient way, so really the cost isnot significant at all. Again, if any added costs come out with better outcome for the patient, I think itísabsolutely worth it.00:16:06.000JOHN BYRNE, MD: My personal belief is that this will become the standard of care. Just like, can you imagine aworld without cell phones? Can you imagine a world without calculators or personal computers, just like this? I
  4. 4. have a cell phone here somewhere, but people canít live without their cell phone. I mean, what weíre doing isweíre just raising the bar, just like anything else in medicine. An imagine, if one needed a LIMA to the LAD,perhaps the most important reconstructive procedure any human will ever have in their entire life, it seems to methat one would want an image of that to make sure that that is not only the correct vessel was bypassed, thecorrect vessel was bypassed in the correct position, and thereís no conduit or anastomosis problems because weknow that 15% of grafts fail in one year, maybe 10%, but this is the most important reconstructive procedureanybody will have in their life, so it seems to me that itís a very reasonable thing to do. If it adds an extra 10minutes to the surgery, I think most Americans probably have no idea that we donít routinely image coronarybypass grafts at the time of surgery.00:17:21.000Iíll just continue on this presentation. Hereís a very interesting case that Dr. Zhao and I did together. Maybe youcan comment, Dr. Zhao.00:17:31.000DAVID ZHAO, MD: This is a post-surgery completion angiography. As you can see, this is the vein graft to the OMbranch. There were two angiographic defects in the vein graft, as you can tell, and those actually were valves andthose you really canít tell from outside, to look at those veins, they look great, but inside, those valves reallycaused sometimes significant stenosis and we identified that and we corrected that, did a revision, and Dr. Byrnecan show you the slides. Now, interestingly, this patient, before we revised this graft, the patient had moderateto severe mitral regurgitation, which he did not have before the procedure. After we put two stents in that veingraft, which we decided to do that because otherwise youíre going to have to take the vein down and do ananastomosis and the vein is not long enough, so we just put a stent in, fixed it, and as you can see, theangiogram below and the entire circumflex area, including the top of the OM, which was not present in theprevious angiogram, now showed up and the mitral valve regurgitation went away, so this is one of those successstories that we fixed the supply to the lateral wall and then completely corrected the hemodynamics as well asischemia.00:19:05.000JOHN BYRNE, MD: So what took so long? What weíre doing is weíre combining 30-year-old technology with 25-year-old technology. Obviously the cameras that we have are all new cameras, you know, theyíre not 25-year-oldcameras and the tools we use for surgery are not old tools, but these are concepts. This is a 25-year-old conceptcombined with a 30-year-old concept, so itís not the technology or concept. Itís not the space or money, really. Imean, to build a hybrid lab is about as expensive or a little bit more expensive as building a state of the art cathlab. Some innovative surgeon or cardiologist should have done this 20 years ago, in my view, but rather itís theabsolute need for cooperation and teamwork. That, in my view, is the real barrier to entry. You needcollaboration and teamwork with Dr. Zhao, from the surgeonís standpoint, to be able to do the imaging aftersurgery as well as the percutaneous coronary interventions as indicated, so what weíre talking about here iscombined procedures of conventional heart surgery with percutaneous interventions, such as minimally invasivevalves and stents or minimally invasive coronary bypass with stents, or later percutaneous valve therapy, so Ithink imaging is going to be part of heart surgery in the future. I think in five years we will not be able to imaginea world without imaging I the operating room.00:20:29.000Again, I use another analogy. The sighted operating room will be to heart surgery what airbags and child carseatsare to cars. Not too long ago, when I was a kid, theyíd just throw us in the back of the station wagon, literally,throw you in the back of the station wagon, drive eight hours to the mountains, and you know, seat belts wereoptional. They were an option in the auto industry. Now you canít bring your child to the grocery store withoutputting him in a carseat. Youíd probably either get arrested or at least be considered a bad parent. I use a trafficanalogy. Just as congested traffic patterns made driving more dangerous and therefore required people to wearseat belts and, indeed, seat belts became a law, so also as coronary disease, at least the coronary disease thatcomes to surgery, becomes more and more complex, weíre going to need imaging to prove that what weíve doneis exactly what we intended to do and also combine the tools that Dr. Zhao is able to provide to get the bestpossible outcome for the patient.00:21:37.000I use this analogy, the blind OR is like flying without instruments. Heís some sort of Cessna plane, propellerplane, and perhaps not too dissimilar from the tragedy with JFK Jr. over Marthaís Vineyard, whereas the sighted
  5. 5. operating room is instrument rated. You know exactly how far that plane is from the water. You know exactly theair speed and how far you are from the target. This is really flying with instruments.00:22:14.000Consider this: a typical surgeon performs about 200 bypasses per year. Each bypass is typically a triple bypass,so thatís 600 bypasses per surgeon per year and each bypass has about 30 critical maneuvers. You could argueis it 10, 20, 30. Whatever it is, itís not trivial, so thatís about 18,000 critical maneuvers per surgeon per year.This is obviously, just statistically speaking, not every single one is going to be perfect. Most are going to be fine.Itís like seatbelts. You can drive down a big highway going 80 miles an hour without a seatbelt and most of thetime youíre okay, but every once in a while youíre not okay.00:22:54.000Or itís like sports. In April 2005, Tiger Woods wins the Masters. A few weeks later, he misses the cut in the ByronNelson, a much lesser tournament. Is he a bad golfer? No, heís a great golfer. Just like a surgeon who happens tobe off by 0.5 mm on one stitch, heís still a great surgeon, but wouldnít you like to check that result, just like theorthopedic surgeons, the plastic surgeons, the gallbladder surgeons, the vascular surgeons, the interventionalcardiologist, every single other surgeon and reconstructive artist and practitioner in life checks his or her results.00:23:31.000To make the point, take an extreme example. I used this slide because I had the privilege of operating on acouple of high profile people recently at my other institution, in Boston, and Iíll tell you, for my own gastricmucosa, I wish I had a completion angiogram in those particular cases. Imagine operating on high profile people,such as Bill Gates or Warren Buffet or Alan Greenspan or the President or Vice President, I think the peopleinterested in their well-being would be very interested in having an angiogram. Indeed, you could probably showthat angiogram to your life insurance agent. You know, you have a mammary to the LAD thatís perfectly patent.You could probably give that to your life insurance agent and say, listen, this thing is good for 30 years.00:24:15.000DAVID ZHAO, MD: Get some discount?00:24:14.000JOHN BYRNE, MD: Yeah, maybe a lower rate. This famous actor, unfortunately, had a LIMA placed through adiagonal. Now, the diagonal may have been very close to the LAD and the surgeon, presumably a superbsurgeon, I do not know who it is, but placed the mammary to the wrong vessel and then of course Mr. Carveyneeded another procedure later on. That would, of course, be totally avoided in a hybrid room because not onlydo you bypass the right vessel, but you bypass the right vessel in the right spot and the runoff is good and theflow is good and so forth. So in my view, in five years we will not be able to imagine a world without imaging incardiac surgery, just like we canít imagine a world without these various modern conveniences.00:25:10.000I think we have some more email questions from the audience. It says will all cardiac surgeons in your grouphave the opportunity to use this suite? Yes, of course, yeah. We have four in our group here at Vanderbilt. Wehave four dedicated adult surgeons and we have two dedicated congenital surgeons. The congenital surgeons, ofcourse, are over at Childrenís Hospital, so the four dedicated adult surgeons all have access to this hybrid suite,as do all the interventional cardiologists, so this is a team effort. The main key point of this process, this concept,is team and itís because of Dr. Zhaoís leadership in cardiology and our participation in heart surgery. I viewmyself as a cardiologist who operates. Dr. Zhao is a surgeon who does interventional. It so happens that Dr.Zhao is a fully trained surgeon from a previous life in Australia, so heís the ultimate hybrid, so he has all theexperience of surgery and interventional cardiology and thatís what makes this a particularly uniquecircumstance.00:26:17.000DAVID ZHAO, MD: All of our interventional cardiologists and invasive cardiologists actually help out for the hybridprocedures. They all come in as needed so they provide timely and efficient service to the cardiac surgery whenthey need it and the same holds true the other way around. If we need it, all those surgeons will be available tohelp us, so itís truly a collaborative effort from both sides.00:26:44.000JOHN BYRNE, MD: The other key feature is that our hybrid ORÖI call it the sighted ORÖthe hybrid OR is in thecath lab. Thatís another key element, that our hybrid cath lab OR is in the cath lab. Itís room 2 in the cath lab, soweíve converted the cath lab into an operating room. The other option, of course, would be to convert an
  6. 6. operating room into a cath lab, but my view is that we need to make it user friendly for our friends ininterventional cardiology and the catheter-based procedures. In my view, all cardiac procedures should be donein the cath lab, should all be done in one spot because weíre going to need the imaging and weíre going to needthe percutaneous technology.00:27:26.000Why donít we take this moment to go to some clips of a procedure that we did yesterday and we can show youan example of a typical coronary artery bypass operation with completion angiography and Iíll narrate this. Righthere is the preoperative angiogram, which shows a tight left main coronary artery lesion, so obviously the LADand the obtuse marginal need to be bypassed. These are fairly reasonable targets. Itís a fairly reasonable riskpatient, you know, a typical surgical patient, left main needs bypass surgery. Dr. Zhao, would you considerstenting this left main?00:28:18.000DAVID ZHAO, MD: No. From our standpoint, itís going to be too risky because the left main and the obtusemarginal are involved. I think the standard of care is bypass surgery.00:28:32.000JOHN BYRNE, MD: Since the patient needs both the LAD and the obtuse marginal bypassed, we, of course, did aregular operation, sternotomy and so forth, as opposed to a minimally invasive mid cap operation with a stent toanother vessel. So in this particular case we did a sternotomy, standard cannulation, and bypass and then we canperhaps roll the tape of what we did yesterday. So this is now routine here at Vanderbilt, completion angiographyon every case. Again, I think the average American ñ indeed, maybe the average physician ñ has no idea thatwe, surgeons, do not perform completion angiograms on every single patient every time. It seems to me to bejust common sense. Anytime I talk to people, laypeople, they say what do you mean, you donít do completionangiograms on patients? Why? You have the camera. The camera has been available for many years. Why not?The barrier is collaboration and cooperation.00:29:42.000Okay, so letís take a look. Of course we do endoscopic vein harvest routinely on all our CABG patients and this isjust a brief clip of the tiny insertion that we use for the endoscopic vein harvest and how the camera ispositioned. We use gas insufflation to create the tunnel. This, of course, is being done by our Pas. Hereís anexample ofÖwell, that was an example of a vein being harvested endoscopically with ligation of the branchesusing endoclips and so forth. After that, we will show you some clips of a regular operation with angiography.00:30:38.000Hereís the endoscope. You see the vein right there. Theyíre applying an endoclip to ligate a branch and thenautomatically apply cautery as well to divide the branch. This is how we harvest the veins on a regular basis. Thepatients are very satisfied with this because it decreases trauma. The incisions are tiny. Patients are verysatisfied with this.00:31:12.000While weíre waiting for the next clip, some more email questions have come in. How many other hybrid operatingroom have been built in the United States? I do not know of all of them. I know of a couple of them that havebeen brought into the news. I know the University of Maryland has opened one. The Texas Heart Institute downin Houston has opened one. I think I believe some folks in Portland have. I think as this concept becomes provento be beneficial to patientsÖultimately it has to be beneficial to the patient and it has to be safe and effective forit to catch on and thatís going to be our job to prove that. Some may argue that itís more expensive. Well, it isprobably slightly more expensive because you have to use the contrast material, you have extra time in theoperating room, which is not cheap, but itís just like seatbelts in car. The auto industry probably said, yeah,those seatbelts, theyíre going to increase our car costs by a few hundred dollars, or environmental protectionlaws increase the price of various goods and services, but thatís in the long run good for people in society, so alsoI think imaging should be a given in cardiac surgery.00:32:46.000Weíre going to show right now, this is a mammary LAD anastomosis, fairly typical of what probably manysurgeons in the audience would do. This is the LAD. Shown here is the mammary artery on the right hand side ofthe screen and then the arteriotomy of the LAD right there in the middle and weíre performing a standardinternal mammary artery to the LAD anastomosis. While that video is playing, let me read some more questions.
  7. 7. What about mid calf and endoscopic mammary harvest, along with stents to non-LAD vessels? Dr. Zhao, do youthink thatís a reasonable approach?00:33:34.000DAVID ZHAO, MD: Yeah. I think if you look at the revascularization strategies, I think itís clear that up to dateLIMA is still the best conduit, particularly in diabetic patients and we know it prolongs life when it has a mortalitybenefit. However, some of the vein grafts did not perform as good as the LIMAs and some potentially even not asgood as the stent, particularly now we have the drug-eluding stents. I think what the patients demand right nowis that they want the best of both. They want the maximal benefit but minimal invasiveness, so I think with thetechnology available to us, particularly with the hybrid approach, we can actually provide minimally invasive LIMAto LAD so we get the mortality benefit and the best conduit and then we can put the drug-eluding stents in thecirc and RCA territory and a patient can have very quick recovery, the best revascularization outcomes, and gohome. Now, thereís a couple of papers published recently. The one major problem people are considering is thequality of minimally invasive surgery. There are issues about graft patency slightly lower than the regular openheart surgery. I think with sighted surgery, we can basically solve this problem and by the time you leave here,you know you have a perfect LIMA. With this, I think outcomes, of course I believe that the outcomes are goingto be great.00:35:20.000JOHN BYRNE, MD: Through a tiny incision in the anterior chest wall, you can imagine doing a mammary to theLAD and a stent to a non-LAD vessel. Stents are probably going to end up being better than vein grafts in thelong run, certainly better than some vein grafts. What you and I have seen is what Iím going to call a conduit-target mismatch, where you have a vein the size of your thumb, applying it to a 1 mm PDA and you know thatísnot going to last, so itís probably better to put a stent, in that circumstance, and then just place the mammary tothe LAD.00:35:56.000Another question from the audience is why not do this in a staged fashion? Obviously we, heart surgeons andcardiologists, have been doing staged hybrids for many years, since the first angioplasty was done in the late 70sor early 80s, weíve been doing staged procedures for many years. Indeed, I might refer the audience to a paperin the Journal of the American College of Cardiology in January 2005, which I wrote with some Boston data onstaged hybrids for valve and coronary disease. Why not a staged hybrid? What are your comments on that?00:36:35.000DAVID ZHAO, MD: The staged procedure obviously in your paper substantially reduced mortality in patients withhigh risk, so it is better than no hybrid at all, but I think in our facility and at least some other facilities, now wecan provide patients a one stop shop. When you come in, you get it all fixed at the same time and, moreimportantly, it probably will reduce a lot of the complications. For example, if you do angioplasty and the patienthas to be on Plavix and several days down the road you operate on someone with a lot of anticoagulation onboard and the bleeding becomes a problem, what we do here is those procedures, we actually give Plavix justbefore the procedure. Because the Plavix was just given, by the time youíre done with the bypass surgery, thebleeding actually is not a major issue. We havenít seen any major incidents of thrombosis either, so I think thecombination of having this done at the same time and giving the medication timely, you can avoid a lot of thecomplications and also the inconvenience for the patient. Now, another aspect is some of those patients maybecome ischemic if you do surgery first or some of those patients you do angioplasty first and then theyíre fluidoverloaded, for example with aortic stenosis and mitral regurgitation, and patients become decompensated. Thenyouíre going to have to really try to do an operation on a very sick patient.00:38:14.000JOHN BYRNE, MD: I think the hybrid concept will simplify an otherwise complex operation. Imaging doing aÖinfact, we were just referred a mutual patient of ours coming down the pike who will need a triple valve, doubleCABG, so what Dr. Zhao is going to do is stent the LAD and the RCA, then the critical valvular lesion is criticalaortic stenosis, so weíre just going to do the aortic stenosis and perhaps an alpha carry through the aorticannulus and then a quick K-suture on the tricuspid and thatís it, call it quits. Otherwise you do a triple valve,double CABG in an octogenarian, I think thatís an operation to be respected, so weíre going to simplify thatoperation by turning basically a triple valve, double CABG into a stent single valve, or maybe valve and a half, ifyou will.00:39:09.000
  8. 8. DAVID ZHAO, MD: Thatís right. Look at the paper you wrote in JACC and that group of patients, very sickpatients, the predicted mortality is 22% and observed the mortality of 3.8%. Thatís mortality, so thatís asignificant drop. I would rather aim at 3.8% column, not the 22% column. That, I think, is a big plus for thepatients.00:39:34.000JOHN BYRNE, MD: I think we have an opportunity to go to a clip showing how theÖone person from the audienceasked whatís the choreography here? This clip shows how the scrub nurse has moved over to the camera, whichis now behind the patient, toward the head of the patient, and has sterilely draped the camera. Then what weívedone, so the scrub nurse moves around the patient, to the front of the head, drapes the camera, and then re-scrubs because weíre so concerned about infection because of all the equipment in the room.00:40:15.000DAVID ZHAO, MD: By the way, we donít have an increased infection rate. We just did our analysis. So weíre verycareful about those issues and we watch that closely.00:40:23.000JOHN BYRNE, MD: Then, just as weíre ready to move the camera, which weíll have a clip of in just a second, ofcourse, these images, these intraoperative angiographies performed with the open chest, the patient is on theoperating room table with an open chest, still cannulated but off bypass, so the heart is full, so the grafts arelaying in the way that theyíre supposed to lay with regard to having a full heart, but the patient is still cannulatedor perhaps the apical cannula is removed, but weíre still Heparinized and so the patient is open and we canít behaving a camera move over an open chest, so we developed a way to drape that open chest very sterilely withthree layers of drapes and I can show you part of that video here.00:41:16.000What this shows is with three layers of sterile drapes and now this is the camera moving in. It takes just a fewminutes. Youíll see how itís coming over the ether screen and Iím catching it now with a sterile bag, so now thecamera has two layers of sterile draping and the patient has three layers of sterile draping in order to preventany potential contamination of the surgical wound, which of course is very important.00:41:56.000Why donít we go to another email question here. How much money does it cost to build a hybrid operating room?Well, this is all new equipment. The fortuitous set of events that happened here at Vanderbilt is that the roomwhere the hybrid lab is was the pediatric cath lab and of course the pediatric cath lab here at Vanderbilt gotmoved over to the Childrenís Hospital, so that left some open space, so we didnít have to kick anybody out,which was nice. So the whole room cost, correct me if Iím wrong, about $2.5 million. How much is a typical cathlab to build, about $2 million, $1.5 million?00:42:39.000DAVID ZHAO, MD: Usually $1.5 to $1.8 million.00:42:41.000JOHN BYRNE, MD: So itís obviously more expensive, but then, you know, if you need new operating rooms,theyíre expensive too, but the beautiful thing about this is what weíre not only combining the tools of technologyof the cath lab and the OR, but weíre also cross training all the personnel. OR techs become cath lab techs. Scrubtechs become cath lab techs. The cardiac anesthesiologists help both in the cath lab and in the operating room.Surgeons are becoming interventionalists and interventionalists are becoming surgeons.00:43:11.000DAVID ZHAO, MD: Thatís right and we actually have a grand plan to try to put together to train hybrid physiciansas well, interventionalists as well.00:43:20.000JOHN BYRNE, MD: Thatís right. Weíre thinking of a training program, where we can integrate both.00:43:24.000DAVID ZHAO, MD: I think thatís important now. The surgeon becomes less and less invasive, and we becomemore and more invasive. At some point weíre going to have to meet together and I think this is the point. Forexample, the percutaneous valve program. Dr. Byrne and I are going to develop it together and join ventures, sothatís the key for this whole process.00:43:48.000
  9. 9. JOHN BYRNE, MD: As surgery becomes more minimally invasive and as interventional cardiology becomes moreaggressive, they blend. At what level of intensity do you call an interventionalist a surgeon, when theyíre doingpercutaneous LVADs or percutaneous valves? At what point of minimal invasiveness do you call a surgeon aninterventionalist, when theyíre doing percutaneous valves? So weíreÖIím a cardiologist who gets to operate. Dr.Zhao is a surgeon who does interventions. So weíre all part of one team.00:44:18.000We have a clip here showing after the camera is in place, Dr. Zhao is performing the imaging procedure throughthe groin. Weíve cannulated the groin with a small catheter thatís removed at the end of the operation. See, heísaway from the camera. The patient is still cannulated, so if we have to go on bypass for any reason, you just takeoff the clamp and youíre on bypass, so itís very safe from that standpoint, so the perfusionist just takes off theclamp and you go on bypass. We have a very good protocol with regard to getting that camera out of there if weneed access to the chest. Basically itís like an escape hatch in an airplane. You hit the button and the camerarights itself and gets out of there.00:45:06.000DAVID ZHAO, MD: Also if you have any defect or anything, you can very easily revise it in this circumstance.00:45:16.000JOHN BYRNE, MD: Letís show at this point the fluoroscope moving out. This is also very smooth. Again, Dr. Zhaojust takes 10 minutes total time from ready for the camera to move in, ready to the camera to move out, andtaking all the pictures takes about 10 minutes.00:45:41.000DAVID ZHAO, MD: We have a charge nurse actually coordinate all those and we have an interventionalist on call,ready to go, so itís very seamless. They usually notify us 30 minutes to go, 20 minutes to go, so we can be readyto do the angiogram and it really doesnít add too much to this whole surgical time but really provides the patientsthe best outcomes.00:46:05.000JOHN BYRNE, MD: Dr. Zhao, hereís an email question. Can a stent be placed in a high grade lesion with almostcomplete or complete occlusion of the coronary artery?00:46:13.000DAVID ZHAO, MD: Yes. We do this all the time. Sometimes we even place stents in vessels that are completelyoccluded. There are several different technologies and equipments we can use to try to go through those totallyblocked arteries. Sometimes you can go through and thatís when we need the surgeons. In this particular setting,we can actually do both. In certain vessels, we can do it. A surgeon can put a graft in a certain vessel. We can doit and we put a stent in. By doing this, we shorten the time, provide the best outcomes, and that is why hybrid isso important to patient care.00:46:56.000JOHN BYRNE, MD: Letís show the anastomosis, the completion angiogram which Dr. Zhao did immediately afterthis operation, with the chest open, with the cannulae in. Thereís the internal mammary artery to the LAD. In myview, if I ever need a CABG or my brother ever needs a CABG or anybody I care about needs a CABG, theyíregoing to get it in room 2, right over there, with a completion angiogram performed by this guy and then Iímgoing to go show it to my life insurance agent because heís going to give me a better rate.00:47:25.000DAVID ZHAO, MD: You can see that the LIMA has a great flow into the LAD and itís really very reassuring thatthatís what the patient has when he leaves this OR. You can see the cannulations and some of those surgicalinstruments are still there.00:47:44.000JOHN BYRNE, MD: All the cannulae are still in. This shows the vein graft to the obtuse marginal, which of coursewe did. We donít show any video of the actual surgery, but this is a vein graft to the obtuse marginal withexcellent runoff. So most of the time it is good, most of the time it is fine. Yeah, most of the time you donít needyour seatbelt. Most of the time, everythingís okay, but we know the data, hard data published in good journals,shows that 10-15% of vein grafts are down at one year and itís almost certainly due to technical issues, and inour data it shows itís mostly conduit. Itís not the anastomosis. Itís probably 1-2% anastomosis. The vast majorityare conduit issues. Dr. Zhao is going to present our data at the American Heart Association meeting coming up in
  10. 10. November and thatís what weíve found. That was for the first 25 or 30 patients. Now we have nearly 100 patientsin our series and weíll be presenting that or at least trying to get that into one of the national meetings.00:48:49.000One question is how many patients did we have so far? About 100. CABG has been a successful operation for solong, why change? I think why change is, you know, look at whatís coming to heart surgery now. Itís diffusemultivessel disease. Because of the success of my friends in interventional cardiology, there are no more what weused to call chip shot CABGs. Thereís a lot of diffuse coronary artery disease with multiple lesions. Maybe weíllput a mammary on one part of the LAD and stent downstream, or weíll put a mammary on an LAD and then themarginal is so small you canít graft it and Dr. Zhao can stent the true circ, or recently we did an endarterectomyto the LAD with a completion angiogram to show that thereís good runoff.00:49:44.000DAVID ZHAO, MD: Thatís actually very important because after endarterectomy really thereís a lot of injury tothe vessel, whether itís patent or not patent. Weíre really reassured it has a great runoff and an excellent result,so it becomes really critical.00:50:04.000JOHN BYRNE, MD: So I think the answer to that question is basically because of the acuity of surgical disease andthe severity is going up so much, imaging will become more important.00:50:14.000DAVID ZHAO, MD: Also, in the current stage and technologies have advanced on both sides and allowed us tocombine both together to provide the best care to the patient. I think now, with coronary intervention, we areworking very hard, progressing into valvular combination of surgery and the percutaneous approach and cell-based transplant. Weíre working very hard in that aspect to actually provide a hybrid approach for the cell-basedtransplant as well, so there are a lot of applications we potentially can use with the hybrid approach.00:50:48.000JOHN BYRNE, MD: Two more questions: Are there any other hospitals in the area with hybrid OR? I do not knowof any. I believe the closest one is probably Houston and maybe the next one would be Maryland, but Iím surethere will be others, as weíve proved. We have to prove that itís useful.00:51:08.000Then, how can I refer a patient to Vanderbilt? We have a 24/7 number. You get a live human who answers thephone within two rings, 24 hours a day, 7 days a week. No voicemail, nothing like that. 615-343-9188. Thatíswhere you get someone who can answer your questions and get you set up for image-guided sighted cardiacsurgery, if thatís what your doctor feels is indicated. Dr. Zhao, do you have any other closing comments?00:51:47.000DAVID ZHAO, MD: I think weíre very excited about this process, as Dr. Byrne said, and weíre going to presentour initial experience in AHA. Interestingly, what we discovered is the graft defect, like Dr. Byrne said, mostly is aconduit defect. Itís about 10-12%. That is very close to what the graft failure rate is reported. Obviously at thismoment we canít really say that 12% is exactly the other 12%. We are engaged in a lot of research projects totry to prove that, but my hypothesis and certainly I believe that by correcting that 10-12% defect, it willsubstantially reduce the early graft failure rate.00:52:34.000JOHN BYRNE, MD: You were saying, Dr. Zhao, that you think an image-guided, an image-confirmed perfect veingraft may be better than some stents.00:52:38.000DAVID ZHAO, MD: Could be, could be. Itís absolutely a possibility and I think definitely for LIMA, thatís a life-saving graft. You want to have a good graft, but you have to prove it.00:52:56.000JOHN BYRNE, MD: I think this is such common sense that anybody who hears about it will think, gosh, it shouldjust be routine. But weíre in the process of trying to prove it and weíll keep you posted. Dr. Zhao at the AmericanHeart Association this November and then weíll be presenting and submitting our data to other major meetingsas time goes on. Weíre out about 100 patients now. Weíll probably have 40 or 50 a month, since we only haveone room so far. So I think there are no more email questions and I think weíll sign off. Thank you for visiting theVanderbilt live webcast of a sighted operating room. We sure appreciate your time and your interest in this. Wethink itís going to raise the standard of care for cardiovascular surgery. It will change the way we think of heart
  11. 11. surgery. In my view, we will not be able to imagine a world without imaging in the cardiac surgical operatingroom in the future. Thank you very much.00:53:58.000DAVID ZHAO, MD: Thank you.00:54:02.000NARRATOR: This has been a live webcast of sighted heart surgery from the hybrid OR cath lab at VanderbiltUniversity Medical Center in Nashville, TN. For more information, to make an appointment, or make a referral,click the buttons below.