TAVR procedure location

[Airlife91]

Advertisement - Members don't see this ad

For those of you that do TAVRs - do these cases happen in a regular OR, hybrid OR, or cath lab? For these cases, do you delineate between patients who accept the possibility of rescue sternotomy (i.e. to rescue catastrophic bleeding by doing a sternotomy, possibly going on CPB, etc)? If so, does that determine the location where these cases are done (i.e. cases with possibility of rescue sternotomy will be done in hybrid rather than cath lab)?

 

[pgg]

Hybrid OR.

Very rarely, we'll do a no-bailout patient in one of the cath labs if there's no hybrid block time available.

 

[DesiredMemberName?]

We do them all in the cath lab unless it’s a trans carotid or something unusual. Then it would go in the hybrid room. Our cath labs are pretty big and very close to the OR. Surgeon is scrubbed in assisting. We’ve done it this way for many years.

I’ve also worked at places that do them all in the hybrid OR.

 

[CopaceticOne]

Unless there is something very weird, they are done in the cath lab at my shop. The cath lab and ORs are very close to each other for what that’s worth.

 

[dchz]

Unless there is something very weird, they are done in the cath lab at my shop. The cath lab and ORs are very close to each other for what that’s worth.

Do they have CPB in the cath lab?

OP,

80%+ are done in hybrid OR. Some are done in cath lab with the ability for CPB in the cath lab.

 

[sevoflurane]

Hybrid OR

 

[psychbender]

My last job, they were done in Hybrid.

My current job, they're done in a cath lab (and yes, there's s bypass circuit against one wall). I think if we had to emergently enter the chest and go on bypass, it would be tight.

 

[CopaceticOne]

Do they have CPB in the cath lab?

For TAVR days they have one in the lab’s sterile core for emergencies as well as a dedicated perfusionist.

The reason is that on TAVR days they do a sort of flip room schedule so there isn’t the delay for turnovers of the physical room. Also, the hybrid ORs are in high demand for complex vascular & other cardiac cases so it just makes logistical sense to ensure they aren’t bumped.

 

[JiPo]

We do in cathlab, which is not that close to the OR. It is small space too. Honestly don’t feel safe doing them in small cathlab but cardiologists insist. We’ve had few cases where things went bad last few years, and had to emergently move to the OR. Not fun transport nor is it safe. Should do them in a hybrid room to crack the chest open on the spot if needed in emergency.

 

[Drwine]

We are a very high volume center and do all in the cath lab. We did some transapical approaches in the hybrid OR but even transcarotid cases are in the cath lab.

 

[JiPo]

We are a very high volume center and do all in the cath lab. We did some transapical approaches in the hybrid OR but even transcarotid cases are in the cath lab.

But how big is your cathlab space? If you have to crack the chest open and go on bypass, can you do it in the same room?

 

[abolt18]

Hybrid (which is adjacent to the Cath lab and looks/feels about the same as the Cath labs. I don't really know how it's different other than being a bigger room).

In training is was usually Cath lab with sometimes hybrid OR.

Also, no circuit in the room. I believe perfusion keeps one nearby but I have honestly not checked. Whoops.

 

[PpfSuxTube]

Cath lab.
No cpb circuit in room. Its not too far away tho.

Word on the street here is that the cardiologists are trying to push the surgeons out of it completely... we haven't had an immediate sternotomy during tavr in 2 + yrs doing approx 500 per yr.

 

[Remxed]

one of our cath lab rooms is a hybrid OR, so we do TAVRs there. Backup pump is in the back room with perfusion on standby. Surgeon scrubs in for deployment.

We just had one case where they crashed onto bypass/MTP this past month.

 

[Drwine]

Cath lab.
No cpb circuit in room. Its not too far away tho.

Word on the street here is that the cardiologists are trying to push the surgeons out of it completely... we haven't had an immediate sternotomy during tavr in 2 + yrs doing approx 500 per yr.

The cardiac surgeons were dragged kicking and screaming to embrace this technology. 🙁 On the flip. side vascular surgeons deserve kudos to be ahead of the curve and embrace endovascular procedures. Vascular surgeons who had nicknames like"hands of stone", HODAD & "I can't quite get it right" when doing open procedures found a second life embracing endovascular procedures.

 

[Drwine]

But how big is your cathlab space? If you have to crack the chest open and go on bypass, can you do it in the same room?

They are huge. Our hospital took a whole floor of a new vascular institute built in 2012 and put in 15 labs for endovascular neurosurgery, interventional radiology, cardiac cath, structural heart and EP. On their website, they advertise that the building has over 1 million square feet. 40 years ago we worked in proverbial closets. The 1986 remodel made everything larger but this is larger by a whole order of magnitude.

I want the value of disposables and implanted devices for 1 week as an amount to retire on. 😉 Just the 7 TAVR valves implanted on Wednesdays would be a nice bonus. It goes without saying that the reps feed everyone well, so no complaints covering those cases.

 

[Maverikk]

Yeah…if you have good cardiologists it’s kind of mind blowing how fast that field has progressed. Where I did tavrs (and I didn’t do a cardiac fellowship) it was Cath lab, no cpb in room but available a few hallways away in the cardiac room. But often days the cardiac surgeon would be doing a case while the tavr was going on. That said the cardiologists were fantastic guys, they had great patient selection, reasonable people, just tte, 90 minute procedure, the cardiologist would talk them through it and obviously did a lot in clinic beforehand. 1 versed, 50 of fentanyl and heparin for most of them. I would imagine in less than 10 years cardiothoracic surgeons will be chomping at the bit to get open AVR experience. Even with bad PAD transcarotid/transapical approaches are there, just more risky…but more risky than open heart I doubt it. One of the vascular surgeons I worked with did EVARs in 60-90 minutes, he said he would do it as an outpatient but Medicare wouldn’t reimburse. He said it was all about knowing the imaging and which ones could be trouble

 

[sevoflurane]

Yeah…if you have good cardiologists it’s kind of mind blowing how fast that field has progressed. Where I did tavrs (and I didn’t do a cardiac fellowship) it was Cath lab, no cpb in room but available a few hallways away in the cardiac room. But often days the cardiac surgeon would be doing a case while the tavr was going on. That said the cardiologists were fantastic guys, they had great patient selection, reasonable people, just tte, 90 minute procedure, the cardiologist would talk them through it and obviously did a lot in clinic beforehand. 1 versed, 50 of fentanyl and heparin for most of them. I would imagine in less than 10 years cardiothoracic surgeons will be chomping at the bit to get open AVR experience. Even with bad PAD transcarotid/transapical approaches are there, just more risky…but more risky than open heart I doubt it. One of the vascular surgeons I worked with did EVARs in 60-90 minutes, he said he would do it as an outpatient but Medicare wouldn’t reimburse. He said it was all about knowing the imaging and which ones could be trouble

I think you can’t compare trans apical or other alternative access to open heart cases.

IMO, Cardiologist and CT surgeons experience and capability varies widely.