Hybrid theatres: nicety or necessity?
Authors: Mark L Field, John Sammut, Manoj Kuduvalli, Aung Oo, Abbas Rashid
Journal: Journal of the Royal Society of Medicine (2009)

In recent years there has been a convergence of approaches to the treatment of cardiovascular disease with combined cardiology, radiology and surgical multidisciplinary team (MDT) based management. This is particularly true with the advent of transcatheter (transfemoral and transapical) aortic valve replacement1 as well as the new combined open and endovascular approaches to thoraco‐abdominal aneurysms,2 including single stage combined coronary artery bypass grafting (CABG) and abdominal aortic endovascular aneurysm repair (EVAR).3 However, there has also been a more longstanding, and commonly although not exclusively, staged hybrid approach in the form of combining percutaneous coronary intervention (PCI) with surgical coronary revascularization and surgical valve repair or replacement in appropriate patients.4–6 As such, it is inevitable new operating enviroments have emerged in the form of so‐called ‘hybrid theatres’ allowing single stage, hybrid endovascular and open intervention for a range of morbidities in children and adults.7,8 This manuscript discusses briefly the design and function of a hybrid theatre, including its perceived advantages and disadvantages. By way of example we review our activity in this environment over the first year of opening. We discuss whether this resource is a nicety or necessity in adopting hybrid approaches.

Design and function of the hybrid theatre
As part of the development of a regional thoracic aortic aneurysm service a purpose‐built hybrid theatre was constructed (Philips) and opened in Liverpool in April 2007. A number of detailed descriptions of hybrid theatres exist8–10 and we therefore restrict the discussion here to a brief overview. Broken down into its basic structural components, the hybrid theatre is simply an operating theatre with built‐in radiological screening capabilities. In truth, however, the hybrid theatre is more than simply the sum of its parts. The bespoke C‐arm image intensifier is built into the ceiling of the operating room and able to move both longitudinally and rotate around the axis of the patient (Figures 1a and b). As such, the theatre complex is designed with ample space, allowing for dedicated cardiopulmonary bypass equipment as well as the paraphernalia associated with general anaesthesia. Other equipment, including transoesophageal echocardiography, cell salvage, electrocautery and pacing, are easily accommodated. Multiple monitors allow easy access to data at all points around the table. High quality overhead lights allow for good visibility. Consistent with a normal catheter laboratory the theatre is designed with a control/viewing room with dedicated image processing, as well as catheter store room, surgical scrub room and anteroom. Lead aprons are available. Other devices such as contrast injector and defibrillator are stored in theatre. It is not only the close proximity of this multidisciplinary equipment which makes this a unique environment, but the fact that it engenders a collaborative approach to the management of complex disease.



Figure 1a and 1b

Hybrid theatre showing the theatre table, roof-mounted C‐arm, perfusion, anaesthetic and surgical equipment




Hybrid approaches to elective cardiovascular disease
The hybrid activity in the theatre is coordinated by two MDT meetings attended regularly by consultant representation from cardiology and radiology, as well as both vascular surgery and cardiac surgery, and intensive care medicine. The specialization of these two groups centres on endovascular approaches to thoraco‐abdominal aortic disease and transfemoral/transapical aortic valve replacement.

Hybrid thoracic endovascular aneurysm repair (TEVAR)/open procedures
A team of three cardiac surgeons with an interest in thoraco‐abdominal aneurysms attend a weekly thoracic aneurysm clinic, with regional and supra regional referrals from the full range of medical specialties. Complex cases requiring endovascular solutions or combined endovascular/open approaches (hybrid or staged) are referred to a monthly MDT meeting attended by cardiac and vascular surgeons with input from both interventional and non-interventional radiologists. During the first year of coming online, a range of truly hybrid interventions have been performed. These include abdominal endovascular aneurysm repairs (EVAR) with simultaneous coronary artery bypass grafting (CABG), arch-related TEVAR with arch vessel bypass, TEVAR with femoral–femoral cross‐over graft, as well as a full range of isolated TEVAR procedures ( Table 1).



Table 1

Surgical activity 2007–2008




Transfemoral and transapical aortic valve replacement
A regular MDT comprising interventional cardiologists, cardiac surgeons and anaesthetists/intensivists discusses possible suitable patients for this approach. To date we have early experience with transfemoral and transpical aortic valve replacement and found the hybrid theatre exceptionally well suited for this activity.