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take advantage of the sterile conditions and of the proximity of their thoracic surgery colleagues. The thoracic surgeons assist with direct aortic and subclavian approaches, but for transfemoral approaches, they mostly work alone. The interventional cardiology team of Truls Råmunddal, MD and Petur Petursson, MD are yet to use their syngo Aortic ValveGuide software routinely as the CoreValve placement has a margin of error, but with the increased attractiveness of anatomically specific valves, correct placement will be greatly assisted by 3D imaging with motion correction. Dr. Råmunddal agrees with Dr. Zachrisson that only specific cases are appropriate for the hybrid OR. “The vast majority of cardiac interventional procedures should be performed in the traditional lab. TAVIs and mitral valve interventions are exceptions. Currently we use the hybrid room for two cases every Wednesday. This may change in the future but for now it suits us.” When asked about the benefits to his patients, Dr. Råmunddal said, “Here at Sahlgrenska we perform TAVIs exclusively on patients who are unsuitable for conventional heart surgery. However, most patients are still candidates for surgical management of complications when needed. We strongly believe that the hybrid OR facilities make the TAVI procedure safer. For example, in the case of life threatening complications such as cardiac tamponade due to rupture of the left ventricle, we can have the chest open in under ten minutes and possibly fix the problem. The hybrid lab provides our TAVI patients with a bigger safety net because of the immediate access to vascular and thoracic surgical expertise.” Vascular Surgery Dr. Håkan Roos adopted the hybrid room concept from his predecessors and it is under his leadership that it has come to fruition. “It’s an obvious advantage to the patient when you don’t have to weigh up the risks of moving a patient in order to convert to open surgery,” he says. “In the hybrid lab, open surgery and interventional procedures are interchangeable.” The entire spectrum of vascular interventions is performed. Complex procedures with fenestrated or branched stents are now feasible in a setting like this and have become standard for vascular surgeons. A technique that the vascular surgeons are refining combines five seconds syngo DynaCT and syngo InSpace 3D/3D Fusion in order to overlay anatomical markers during EVAR procedures (Fig. 1). Interventional radiologist, Giasemi Koutouzi, MD regularly joins the vascular team to assist with post processing and fusion on the syngo X Workplace. In the beginning of the hybrid lab journey, the vascular team assisted the cardiac team to learn certain skills needed during TAVI procedures. The 18Fr aortic valve delivery system sometimes requires dilatation of the iliac artery, a skill that the vascular surgeons shared with the cardiologists. Spine Surgery The orthopedic spine surgeons came rather late to the Artis zeego party. In 2011 spine surgery (along with pulmonary, orthopedic, and renal surgery) had not been considered as an area that would hugely benefit from using the Artis zeego, but in hindsight, the increased power and Automap functionality make it far superior to the old-style mobile C-arm systems that spine surgeons used to use. As the room was not being fully utilized by the IR and vascular teams, the spine surgeons were invited to use the hybrid lab on Mondays and have not looked back since. “The opportunity to have access to a room with an imaging system like the Artis zeego is of great value,” says Per Wessberg, MD. Dr. Wessberg was excited by the image quality and started to use the hybrid operating room for complex spinal procedures. “For adolescent scoliosis procedures the Artis zeego brings surgery to a new level.” With a portrait syngo DynaCT and its excellent spatial resolution he is now able to place spinal implants very precisely. On top of this, if a screw is not in the ideal position it can be corrected there and then. A syngo DynaCT at the end of the procedures helps the surgeon to end surgery knowing that all screws are placed optimally. For this final 3D acquisition, SUH is using the low-dose protocol 5s DR-L that requires only 30% of the dose of a regular 5s DR protocol. For very young patients SUH is evaluating a special protocol that acquires only half the number of projection images, thus even further reducing the dose by a factor of two. The surgeons mainly use the 3D volume for control of the screw placement and as a result routinely use under 30 seconds of fluoro for scoliosis and fusion cases. The Hybrid Nurse Monika Wass is an OR nurse with over 20 years of experience at Sahlgrenska. She has found it challenging but interesting to amalgamate with the IR nurses. “The IR nurses were interested in evolving their sterile technique and we have learned more about handling catheters and wires” says Wass, “in the beginning we had many meetings and practiced simulated cases but nothing can 100% prepare you for the first live case. You need to be very flexible and open minded and even after two years with the Artis zeego, we still learn new things.” Roos mentions that the long term goal is for nurses from either background to evolve towards becoming “hybrid nurses”. Although the global trend is moving toward interventional procedures, Wass warns nurses to keep up their surgical skills. “When an interventional procedure goes wrong, the patient can go downhill very quickly. At this time the physicians need an experienced and competent surgical nursing team by their side. Stay current,” she advised. Future Perspectives The hospital regularly organizes “Intro days” where clinicians doing a wide variety of procedures (such as trauma and tumour surgery) are invited into the hybrid lab and shown the features of the Artis zeego that would benefit their specialties. Advantages common to all specialties include Automap, Surgery Multidisciplinary Use of Orthopedic OR 68  AXIOM Innovations | December 2013 | www.siemens.com/angiography


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