[Physician Comment] Hybrid operating rooms shed light on coronary status in aortic dissections

Feb 10th – Hybrid OR suites streamline pre- and post-operative assessment of whole body tissue perfusion in acute type A dissections, informing more tailored therapies.

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1. Hybrid OR suites streamline pre- and post-operative assessment of whole body tissue perfusion in acute type A dissections, informing more tailored therapies.

2. In the hybrid OR, shorter delay time and the ability to operate on complications immediately enabled angiography to be performed preoperatively for 57% of acute type A dissections.

3. Coronary artery bypass grafting and endovascular interventions occurred concurrent with aortic repair if sites of ischemia were found.

For type A aortic dissections, a hybrid operating room aims to maximize the information gained from preoperative imaging without sacrificing time to definitive surgical correction. The seven-year experience of this center showed many of the patients who underwent angiography showed signs of end-organ malperfusion and underwent endovascular intervention as a result. It is unknown thus far whether endovascular procedures before surgery produce better outcomes than immediate aortic surgery.

Click to read the study in The European Journal of Cardio-Thoracic Surgery

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Image: CC/MilitaryHealth

1. Hybrid OR suites streamline pre- and post-operative assessment of whole body tissue perfusion in acute type A dissections, informing more tailored therapies.

2. In the hybrid OR, shorter delay time and the ability to operate on complications immediately enabled angiography to be performed preoperatively for 57% of acute type A dissections.

3. Coronary artery bypass grafting and endovascular interventions occurred concurrent with aortic repair if sites of ischemia were found.

Study author, Dr. Tsagakis, talks to 2 Minute Medicine: Universitätsklinikum Essen

OP-WHE_Juli09_037“The angiography is performed in all patients on the operating table since the patient  is fully prepared for immediate thoracotomy and surgery and the hemodynamic is controlled from the anesthetist.

Generally, we see no contraindication for angiography on hybrid table except of patients with uncontrolled hemodynamics. However, also in cases complicated with severe tamponade angiography is performed after sternotomy and tamponade release; during the angiography the team is ready for begin of the aortic surgery.

In patients <50y the incidence of coronary artery disease is low and coronary angiography can be avoided. However, the angiography support us with real-time information about the extent of dissection and the characteristics of malperfusion (static or dynamic), especially in abdominal aorta und iliac arteries. Therefore and especially in DeBakey type I dissection we perform angiography in every patient in order to evaluate the malperfusion situation followed by endovascular repair first, if required.”

Primer: Type A aortic dissection is a surgical emergency in which time to operation is of the essence. Unfortunately, decreased time to the operating room often comes at the cost of detailed diagnostic imaging information. The hybrid operating room is a setting in which cardiac surgery and cardiac catheterization tools are both accessible with a team of cardiac anesthesiologists, interventional cardiologists, and cardiac surgeons present. It has been shown to be successful for transcatheter aortic valve replacements, and is presented in this paper as potentially advantageous in the management of acute type A aortic dissections as well.

This [retrospective] study: reviewed data from March 2004 to March 2011 at the West German Heart Center in Essen, Germany, during which a total of 124 patients were diagnosed with acute type A aortic dissection. 100% of patients received transesophageal echocardiography and 57% received angiography in the hybrid operating room before surgery. From malperfusion detected in these diagnostic imaging procedures, 32% of patients underwent concurrent coronary artery bypass grafting and 23% underwent primary endovascular intervention. 7% of patients needed postoperative endovascular interventions due to persistent malperfusion. The in-hospital mortality rate was 16%.

In sum: For type A aortic dissections, a hybrid operating room aims to maximize the information gained from preoperative imaging without sacrificing time to definitive surgical correction. The seven-year experience of this center showed many of the patients who underwent angiography showed signs of end-organ malperfusion and underwent endovascular intervention as a result. It is unknown thus far whether endovascular procedures before surgery produce better outcomes than immediate aortic surgery.

Click to read the study in The European Journal of Cardio-Thoracic Surgery

By Gina Siddiqui and Allen Ho

More from this author: Ischemia-reperfusion injury central in early mortality after thoracic endovascular aortic repair (TEVAR), An argument against hospital admission for heart failure

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