Conversations in Cardiology: Where to Build a Hybrid Lab

Morton Kern, MD, of VA Long Beach Healthcare System and University of California, Irvine, often engages his colleagues via email in brief, informal dialogue on clinically relevant topics in interventional cardiology. With permission from the participants, TCTMD presents their conversations for the benefit of the cardiology community. Your feedback is welcome—feel free to comment at the bottom of the page.

Stephen Ramee, MD (Ochsner Medical Center, New Orleans, LA), asks:

Hi Mort,

I have a question for the group. If you are building a new hybrid lab for structural heart procedures, where would you put it and why? In the cath lab suite or in the OR?

Kern replies:

The OR. More versatility, use of the OR recovery and same-day intake area, quicker access to anesthesia on the fly.

I wish we could build one.

Larry S. Dean, MD (UW Medicine, Seattle, WA), replies:

Cath lab and don’t try to build it to serve the many “masters.”

We have three hybrid labs (two in the OR and one in the cath lab area), and I’d be happy to give you more insight into the potential pitfalls.

Kirk Garratt, MD, MSc (ChristianaCare, Newark, DE), replies:

Agree with Larry that the suite needs to be purpose-built, not all-purpose. Having said that, a well-designed structural lab can handle a lot of different work. I’m less committed to being in the cath lab—mostly that eases inventory management and is convenient. You might get better cooperation from surgeons, anesthesia, and periop teams if you’re in their environment. If you have to flex on something, I’d say flex on lab location (within reason).

Theodore Bass, MD (UF Health, Jacksonville, FL), replies:

I agree.

Cath lab definitely. For reasons mentioned and also you avoid the politics and loss of control of the room created by an OR environment. At our place, the processes, room turnover, inventory control, support personnel, control of costs, and many other efficiencies are immeasurably better cath lab versus OR. Not sure how universal that is elsewhere.

James Blankenship, MD (University of New Mexico, Albuquerque), replies:

At my previous institution we built the hybrid lab in the cath labs and it worked out well from the standpoint of the cardiologists and cath lab management, although the surgeons and anesthesiologists were less happy. At my current institution we will be using a room in the OR, although we will revisit this debate as we plan for a new structure with ORs and cath labs over the next few years.

Factors that may influence the decision include influence (who has more bargaining leverage) and geography (some cath labs and some ORs are so limited in space that a large new hybrid lab just won’t fit and retrofitting an existing lab or room is not feasible).

Another benefit to having the hybrid lab in the cath lab, besides those mentioned by Ted, is that when not being used for structural procedures it can be used for regular cath cases and nonsurgical backup, non-general anesthesia structural procedures.

David Cohen, MD (Kansas City, MO), replies:

One option to consider for those of you who are building a substantial new facility is the setup at the “new” Mid America Heart Institute (which is about 8 years old now, I think). One of the things the architects got right was colocation of the cardiac surgical ORs and cath labs in space that is directly adjacent. With one hybrid lab in the OR and one in the cath lab, it is trivial to move back and forth between the two spaces for efficient TAVR days and for other types of collaborative procedures.

Ajay Kirtane, MD (NewYork-Presbyterian/Columbia University Irving Medical Center, NY), replies:

One challenge of putting it in the OR is that if OR slots are limited, sometimes non-fluoro cases are/can be put in there, which is not the best utilization of resources.

Of course I’m biased though 😉

Duane Pinto, MD, MPH (Beth Israel Deaconess Medical Center, Boston, MA), replies:

Another challenge is dealing all of the OR rules and regulations. Scheduling/rescheduling is a flog. Dealing with those processes for preliminary reports, etc. Plus, I like my coffee in the control booth and always forget to take my wedding ring off.

Aaron Kaplan, MD (Dartmouth-Hitchcock Medical Center, Lebanon, NH), replies:

Agree with keeping it in the cath lab, though best model moving forward is to have cath lab, cardiac, and vascular ORs colocated. Nick Hopkins has done this at the Gates Vascular Institute in Buffalo. Sounds like they have a similar setup at Mid America.

Jonathan Tobis, MD (UCLA Health, Los Angeles, CA), replies:

When UCLA built its 'new' hospital 10+ years ago, we decided to have the cath labs next to the OR on the second floor, but in a separate suite of six labs. It is down the hall from the OR and very easy for the surgeons and anesthesiologists to move in and out of the cath labs. We have the largest room for TAVR but ECMO fits into most of the labs. The alternative was to put the cath labs on the first floor with the ER, but this works out pretty well even for the few STEMIs in shock. If needed, they get stabilized in the ER before being transferred. A hybrid room in the OR suite would become another surgical suite.

Paul S. Teirstein, MD (Scripps Clinic, La Jolla, CA), replies:

At Scripps we built our new hospital with two hybrid labs in the OR and none in the cath lab. I would not advise this. It’s great for the surgeons, and the hybrid labs are now used a lot by vascular surgery, which is a positive for them. But, most of us cardiologists like to stagger cases in more than one room, and it does not feel at all comfortable doing a TAVR in the OR’s hybrid room while another patient of yours is being put on the table in the cath lab. For that reason, we do pretty much all our TAVRs in the cath lab, including transaortic and transcarotid.