The University of Michigan in Ann Arbor sports one of the finest medical centers in America. We won’t even mention the football team. One of the reasons U of M’s clinics are at the forefront of what they do is because the university gives physicians the freedom to seek new ways of doing things. This includes building new facilities designed to handle the kind of medical practices that are expected to take place in the near future. One such facility is the recently built hybrid operating room at the Frankel Cardiovascular Center, a room which combines a high-end cath lab with a traditional open-chest surgical environment. The first case in the new OR was performed in July of this year.
Its genesis was the culmination of efforts led by Dr. Stanley Joseph Chetcuti, an interventional cardiologist who also sees himself as a technology fanatic lucky enough to combine his passion and profession. We were fortunate to receive a tour from Dr. Chetcuti of his hybrid OR, for which he displays an almost fatherly affinity. We visited on a weekday afternoon, after all the procedures of the day were complete and when we were able to explore the place without disrupting anyone’s clinical work. We put on a bunny suits and were led inside.
Walking into the hybrid OR, the immediate impression is that of a spacious area full of brand new, high-tech gadgets. It may be the largest facility of its type in the U.S., if not the world. The extra space makes it possible to wheel equipment quickly to and from the patient, particularly important when a catheter-based procedure goes awry and a conversion to an open heart surgery is suddenly required. Additionally, a larger clinical staff, including surgical trainees, can be accommodated without crowding.
The imaging in the hybrid OR is provided by a Siemens ARTIS pheno angiography system, a device Dr. Chetcuti was particularly proud to have gotten his hands on and one we excited to check out. Cleared by the FDA only in March of this year, University of Michigan’s hybrid OR was the first installation of the ARTIS pheno. The system is a floor-based robotic fluoroscope that provides top of the line imaging while significantly reducing the radiation exposure of the nearby clinical staff. Because the device doesn’t have cables reaching into the ceiling, the leaded glass shields that protect clinicians working directly on the patient can be moved around freely and don’t have to be considered when repositioning the fluoroscope.
Much of the radiation reduction is due to Siemens’ zen40HDR low noise flat panel detector, GIGALIX X-ray tube, and pre-filtration, but also because of advanced software that facilitates the creation of quality images while using less radiation during each exposure. The appropriate radiation dose can even be automatically selected by the apparatus based on a number of factors, which allows the clinicians to begin the procedure faster while reducing the exposure of everyone involved. Consequently , the amount of contrast agent to inject can also be lowered in a variety of cases thanks to the ARTIS pheno.
While working inside the hybrid OR, clinicians wear dosimeter badges that measure everyone’s exposure to X-ray radiation. Clinical personel can see their personal exposure in real-time, allowing them to change location and immediately see the impact that makes. A radiation safety group meets on a regular basis to evaluate the data and to make suggestions on how to improve the numbers. So far, Dr. Chetcuti believes that exposure has been lowered by about a factor of four, a remarkable achievement in an industry constantly struggling to do so. To further lower how much radiation actually strikes clinicians’ bodies, U of M now mandates even leaded glasses and head protection.
Computer displays are seemingly everywhere and the large screens can be easily split to show imaging, vitals, and other live data. Moreover, 3D digital fusions can be automatically created that combine pre-op imaging scans, including transesophageal echocardiography, with live intra-op fluoroscopy data. These give physicians a detailed and intuitive view of the relevant anatomy, as well as depth perception, as they guide catheter-based tools and devices toward the heart. Digital markers placed on the ultrasound scans can be automatically transferred to the fluoro image, which is another regularly used tool to provide intuitive intra-op navigation.
Dr. Chetcuti showed us some of the implants that he installs on a daily basis in the hybrid OR, including Medtronic and Edwards TAVRs (transcatheter aortic heart valves), Boston Scientific’s Watchman device, which helps to prevent strokes by occluding the left atrial appendage, and Abbott’s AMPLATZER Septal Occluder, used to treat atrial septal defects. These devices are impressive in their intricate detail, a good deal of which is the result of manual craftsmanship that’s done by anonymous weavers.
Some of these devices cost tens of thousands of dollars, which may be surprising even considering the handiwork that goes into them. But they are a result of a tremendous amount of research, testing, trialing, and focused attention that few similarly sized devices receive in the consumer world. Even something as simple as the flaps in a replacement heart valve are de-cellularized animal tissues that have to be produced in an extremely controlled fashion to ensure that they work perfectly for many thousands of heartbeats.
And when one considers that the entire hybrid OR is setup to implant these tiny devices that only work well when properly delivered and positioned, it becomes even clearer that everyone and everything has to work together to make sure each patient gets the best possible outcome.
Dr. Chetcuti believes that soon we’ll be seeing the introduction of living tissue valves that slowly disintegrate as patient’s own tissue takes over, resulting in a fix that doesn’t leave an implant behind. This may sound overly optimistic, but Dr. Chetcuti himself wouldn’t have believed five years ago that he’d be able to do things he does now on a daily basis.
While optimal patient outcomes are its primary focus, U of M is also a teaching hospital and almost all of the procedures involve students at various levels of education. As such, the control room in the back of the hybrid OR has space for about a dozen people to witness the procedures taking place. Because there are important details that are hard to see from the back of the control room, the operating room has cameras on the walls that an instructor can use to zoom in on important aspects. The images come through on a large screen TV hanging above the main window looking into the OR. The same TV can display output from the ARTIS pheno C-arm, clinical monitors, or other devices being used. Moreover, the same feed can be displayed on screens to students outside the hybrid-OR, useful when larger groups have to be trained in a particular procedure.
We’d like to thank Dr. Chetcuti for showing us the new hybrid OR and congratulate everyone at U of M for building such an impressive facility.