Hybrid Operating Rooms for Transcatheter Aortic Valve Replacement: A Must-Have or Nice to Have? [editorial]

Kentaro Hayashida
2018 JACC. Cardiovascular interventions  
T ranscatheter aortic valve replacement (TAVR) has emerged as a well-established treatment for patients with high-and intermediate-risk symptomatic severe aortic stenosis (AS) (1,2). This therapeutic procedure is now reaching its maturity, and a minimalist approach (using local anesthesia and percutaneous closure) is becoming more common in contemporary TAVR (3,4). Despite the trend toward more simplified procedures, hybrid operating rooms (ORs), which combine features of both the
more » ... h the catheterization laboratory (high-quality fluoroscopy, imaging, and radiation protection) and OR (fully equipped surgical facilities and a higher clean level), have been advocated to be ideal for TAVR to secure safety and efficacy for better quality of imaging and potential risk for surgical conversion. However, not all hospitals are equipped with hybrid ORs, because of their high cost and requirement of larger space. In this issue of JACC: Cardiovascular Interventions, Spaziano et al. (5) report a comparison of clinical outcomes among patients who underwent TAVR in a hybrid OR with those who underwent TAVR in a catheterization laboratory in a French national registry that enrolled 12,121 patients. The investigators observed that procedure location was not associated with short-or mid-term mortality, regardless of vascular access site. The potential advantage of a hybrid OR over a catheterization laboratory is thought to be ease of emergent surgical conversion in case of severe complications (e.g., annular rupture) and lower infection rates due to the more aseptic environment. In this study, no significant difference in 30-day mortality was found among patients who underwent conversion to surgery between the 2 initial procedure locations (35.9% and 47.8% for the hybrid OR and catheterization laboratory, respectively, p ¼ 0.36). Among patients who developed annular rupture, although conversion to surgery was numerically more frequent in the hybrid OR group (29% vs. 13%; p ¼ 0.28), this did not result in a difference in mortality (62% vs. 74%; p ¼ 0.38). The investigators also demonstrated that patients who were suitable to have surgical conversion (regardless of where this took place) had lower 30-day mortality than those who were not (40% vs. 76% for conversion and no conversion, respectively, p ¼ 0.05). Even in this very large registry, the occurrence of severe complications requiring surgical conversion was quite low; therefore, it is difficult to draw a definite conclusion. However, these results also suggest that mortality after severe procedural complications may be associated mainly with the "suitability" of surgical conversion, including severity of complications, general status, and availability of surgical conversion, rather than initial procedure location. Indeed, this registry was conducted between 2013 and 2015, and most French TAVR centers were already well experienced. Therefore, surgical conversion was required in only 0.5% of cases. In contrast, in Japan, a hybrid OR is an essential requirement to start a TAVR program, and this regulation has been led by the Japanese TAVR committee and the Pharmaceuticals and Medical Devices Agency. Now, there are more than 140 TAVR centers in Japan, and all hospitals are equipped with hybrid ORs.
doi:10.1016/j.jcin.2018.07.037 pmid:30409277 fatcat:7bn4i5bhzfebfiiov7dtxkfn6y