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Physicians are faced with a number of challenges in the current medical environment. These challenges include an ageing population - many with multiple comorbidities - rapid advances in technology, increased costs to provide these services, and the need for a working environment that can allow for the adaptation of this process1. The cardiovascular surgeon has not been immune to these challenges.
There has been a rapid evolution in the treatment of cardiovascular disease, mostly due to the advancements in transcatheter technologies. These include transcatheter heart valve therapies, stentgraft treatment of aortic aneurysms and other endovascular interventions. This has also resulted in the integration of open surgical procedures with transcatheter interventions. These minimally invasive or hybrid procedures have resulted in markedly decreased morbidity and mortality for elderly or polymorbid patients who would otherwise be exposed to major operative complications.
The evolution in the treatment of cardiovascular disease imposes a strain on our current operating theatre environment – it was not designed for modern day cardiovascular surgery. To improve the quality of cardiovascular care, the cardiovascular surgeon has to develop an operating room that more readily integrates the latest imaging and procedural technology – the Hybrid Operating Theatre (OT). The Hybrid OT is also the ideal facility for increasingly complex procedures performed by the interventional cardiologist, particularly in the field of structural heart disease, and current cardiovascular catheterisation laboratories do not have the back up support afforded by the Hybrid OT.
Imaging devices have been used in operating rooms for a long time. Mobile C-arms, ultrasound and endoscopy are basic prerequisites for operations in many Dr Victor Chao, Consultant, Department of Cardiothoracic Surgery, National Heart Centre Singapore Dr Paul Chiam, Consultant, Department of Cardiology, National Heart Centre Singapore New Spectrum of Care with NHCS’s Hybrid OT surgical fields. However, the Hybrid OT needs, in addition to standard surgical specifications, high-quality imaging equipment equivalent to angiographic systems used in interventional radiology and cardiology.
 These include high-end fluoroscopy, 3D angiography, CT-like imaging and intravascular ultrasound, which allow the visualisation of thin guidewires, quantification of small vessel diameters, and evaluation of delicate anastomoses. Also, the facility for seamless archiving of images and post-processing capabilities are important for the imaging workflow.
In addition, the Hybrid OT should also possess all the essential equipment available in a state-of-the-art cardiovascular operating theatre: laminar airflow with frequent air exchanges, large flat panel displays for hemodynamic monitoring as Figure 1. The hybrid OT combines the best of the operating room with high-end imaging equipment. well as real-time and stored fluoroscopic images, and gas and electric pendants for anaesthesiology and perfusion.
The new Hybrid OT at the National Heart Centre Singapore incorporates a robotic state-of-the-art imaging system, which combines all the abovementioned requirements of surgery, anaesthesiology and invasive cardiology to provide excellent imaging quality. The system has a virtually limitless positioning ratio, performs real-time 3D image reconstruction and has added functional space for collaboration among physicians and surgeons from multiple disciplines.
 The on-site presence of advanced imaging is a way to ensure the precision and optimal safety of many surgical procedures. The high-end imaging systems available provide quick and detailed information for shorter, more accurate treatment with substantially less X-ray exposure when compared to traditional devices. Complex cases are more easily treated, since the suite is designed to handle both minimally invasive percutaneous, hybrid operations and open surgical procedures.2
This also means a one-stop point of care for many patients who can have imaging and treatment in one setting, where multiple trips were required in the past. The new OT will create the optimal setting for interventionists and surgeons to work synergistically, allowing operators to transit seamlessly from minimally invasive to open surgical procedures (when necessary), thereby minimising the risk to patients, reducing the overall time in the hospital and allowing a speedier recovery.
The hybrid OT is therefore truly patientcentred, bringing multiple care providers and varied expertise right there in one room at the patient’s side. Of course, this requires collaboration between departments and disciplines, working in alignment to achieve success.
 An integrated setting also means saving time and manpower because more procedures can be completed in the same room by the existing staff without increasing the strain on the team and without relocating equipment or personnel from another department.
Prior to each case, all team members, including the surgeon, interventionist, nurse, scrub technician, anesthetists and imaging technologists, meet to communicate the goals of the procedure and what type of imaging should be used to accomplish them.
Below are some of the types of cardiac and vascular procedures which can be performed in the hybrid OT:
• Minimally invasive cardiac surgical procedures
• Combined carotid artery stenting and open heart surgery
• Combined angioplasty with minimally invasive valve surgery
• Percutaneous (catheter-based) heart valve replacement and repair
• Treatment of cardiac arrhythmias
• Aortic aneurysm repairs
• Combined open and endovascular procedures
• Percutaneous (catheter-based) vascular procedures
 Truly, the sky is the limit.
For patients, we expect treatment in the new Hybrid OT to result in:
• More minimally invasive procedures
• Fewer surgical complications
• Shorter hospital stays
• Faster recovery time
• Improved patient outcomes
• Treatment for patients who otherwise would not have an option
In conclusion, the hybrid OT facilitates a whole new spectrum of cardiac and vascular surgical therapies. It is an essential resource of every cardiovascular centre.
References
1) Eagleton MJ, Schaffer JL. The Vascular Surgery Operating Room. Endovasc Today, Aug 2007; 25 – 30.
2) Kpodonu J, Raney A. The cardiovascular hybrid room a key component for hybrid interventions and image guided surgery in the emerging specialty of cardiovascular hybrid surgery. Interac CardioVasc &Thor Surg, Oct 2009; 9: 688 - 692.
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